CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 112 45.750000 1692.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 10 9.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 101 224.500000 8306.5000 37.0000
Subtotal (Total Children Is Unduplicated) 161 279.500000 9999.2500 35.7755
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 26 46.000000 2300.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 70.500000 5248.5000 74.4468
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 19.000000 1425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 21.500000 1612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 50.000000 2775.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.000000 675.0000 75.0000
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 94 217.000000 14087.0500 64.9173
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Total 496.500000 24086.3000 48.5122
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Number of Children (Unduplicated) With at Least One Service 194
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Center 03
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 1 0.250000 9.2500 9.2500
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
610 496.250000 24077.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 611 496.500000 24086.3000 9.2500