CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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 5 12.250000 425.5000 34.7347
Subtotal (Total Children Is Unduplicated) 5 12.250000 425.5000 34.7347
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
Subtotal (Total Children Is Unduplicated) 8 16.000000 1200.0000 75.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.000000 350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 1.0000 1.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 6.000000 428.6400 71.4400
Subtotal (Total Children Is Unduplicated) 4 14.000000 779.6400 55.6886
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Total 42.250000 2405.1400 56.9264
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Number of Children (Unduplicated) With at Least One Service 17
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Center 07
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
28 42.250000 2405.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 28 42.250000 2405.1400 0.0000