CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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 668 319.250000 11779.5000 36.8974
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 760 691.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 645 2004.750000 69168.7500 34.5024
Subtotal (Total Children Is Unduplicated) 1470 3015.750000 80948.2500 26.8418
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 12.500000 795.7500 63.6600
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
Subtotal (Total Children Is Unduplicated) 20 33.000000 2283.2500 69.1894
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 20 24.500000 1225.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 26.000000 1300.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 2.000000 20.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 10.000000 714.4000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 4.000000 285.7600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 15.000000 1071.6000 71.4400
Subtotal (Total Children Is Unduplicated) 40 83.500000 4716.7600 56.4881
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Total 3132.250000 87948.2600 28.0783
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Number of Children (Unduplicated) With at Least One Service 1477
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Center 01
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 1 2.000000 150.0000 0.0000
S 15 13.750000 597.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4658 3021.000000 81263.3800 0.0000
Other 86 95.500000 5937.1300 0.0000
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Total 4760 3132.250000 87948.2600 0.0000