CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 398 211.000000 7807.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 286 195.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 268 757.000000 28009.0000 37.0000
Subtotal (Total Children Is Unduplicated) 669 1163.750000 35816.0000 30.7764
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 12 12.000000 600.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 84.4600 42.2300
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 100.5800 40.2320
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 10.000000 510.5000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 40 49.500000 2554.2900 51.6018
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 157 188.750000 9437.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 6 3.250000 81.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 129 187.500000 9375.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 8 5.250000 131.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 97 239.750000 11987.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 39 42.250000 2112.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 103 161.000000 8050.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.000000 50.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 98 142.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 33 103.750000 5187.5000 50.0000
INTR-T1013-INTERPRETER 3 32.250000 1612.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 631 5321.000000 53210.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 45 173.500000 12394.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 26 111.000000 6349.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 20 96.250000 6790.3800 70.5494
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 59 314.750000 22357.9000 71.0338
TRAV-TRAVS-Travel by mile 548 51416.00000 22884.7500 0.4451
Subtotal (Total Children Is Unduplicated) 679 58541.25000 172030.0700 2.9386
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Total 59754.500000 210400.3600 3.5211
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Number of Children (Unduplicated) With at Least One Service 880
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Center 52
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 3 3.000000 110.0000 110.0000
D 11 10.250000 530.3500 0.0000
S 3 1.500000 55.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 6246 58008.250000 167668.5000 164808.9600
2884 1731.500000 42036.0100 174.0100
Other 0 0.000000 0.0000 0.0000
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Total 9147 59754.500000 210400.3600 165092.9700