CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 19 27.500000 1017.5000 37.0000
Subtotal (Total Children Is Unduplicated) 19 27.500000 1017.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.250000 62.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.000000 675.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 10.000000 750.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 52.000000 2886.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 55.000000 4125.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 47 136.750000 9187.0500 67.1814
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.000000 73.3200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 2.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 123 616.250000 30812.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 36.000000 2571.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 7.000000 500.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 25.000000 1786.0000 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 133 691.250000 35853.7000 51.8679
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Total 855.500000 46058.2500 53.8378
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Number of Children (Unduplicated) With at Least One Service 155
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Center 53
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 25 28.673380 1702.5498 797.6200
D 4 5.000000 295.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 34 35.000000 2211.2400 2211.2400
T 10 10.000000 564.3200 564.3200
718 758.326620 40218.7602 0.0000
Other 15 18.500000 1065.6300 0.0000
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Total 806 855.500000 46058.2500 3573.1800