CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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
CASE-CASE-NON-TCM CASE MANAGEMENT 4 2.500000 92.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 8.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 71.000000 2627.0000 37.0000
Subtotal (Total Children Is Unduplicated) 33 82.000000 2719.5000 33.1646
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 22.500000 1687.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.500000 562.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 16.500000 1200.0000 72.7273
Subtotal (Total Children Is Unduplicated) 27 59.000000 4362.5000 73.9407
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 9 5.500000 275.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 11 17.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 34 178.500000 8925.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10 25.000000 250.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 5.000000 357.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 5.000000 357.2000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 66.000000 4715.0400 71.4400
Subtotal (Total Children Is Unduplicated) 52 302.000000 14879.4400 49.2697
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Total 443.000000 21961.4400 49.5744
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Number of Children (Unduplicated) With at Least One Service 90
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Center 54
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
443 443.000000 21961.4400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 443 443.000000 21961.4400 0.0000