CMS/EIP Fiscal Report Center: 09
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:MED
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 993 3410.250000 126105.2500 36.9783
Subtotal (Total Children Is Unduplicated) 993 3410.250000 126105.2500 36.9783
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 120 185.500000 13770.0000 74.2318
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 65 87.500000 6562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 47 67.500000 5062.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 128 205.500000 11405.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 76 100.000000 7500.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 216 682.000000 46839.8000 68.6801
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 34 178.000000 8900.0000 50.0000
Subtotal (Total Children Is Unduplicated) 34 178.000000 8900.0000 50.0000
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Total 4270.250000 181845.0500 42.5842
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Number of Children (Unduplicated) With at Least One Service 997
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Center 09
Flag Claims Units Chgs Paid
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R 3 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 161 184.750000 9966.2500 225.2500
P 4430 4081.000000 171712.3000 282712.0500
D 0 0.000000 0.0000 0.0000
S 1 1.250000 46.2500 46.2500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4595 4270.250000 181845.0500 282983.5500