CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 63 57.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 200 601.500000 22255.5000 37.0000
Subtotal (Total Children Is Unduplicated) 200 659.000000 22255.5000 33.7716
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.500000 138.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 96 174.500000 13087.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 54.000000 4050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 28.000000 2100.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 90 164.000000 9102.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 28.000000 2100.0000 75.0000
Subtotal (Total Children Is Unduplicated) 129 456.000000 30953.2500 67.8799
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
CONIF-CONIF-CONSULT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 11.000000 550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 12.000000 120.0000 10.0000
Subtotal (Total Children Is Unduplicated) 1 24.000000 720.0000 30.0000
-----------------------------------------------------------------------------------------------------------------------
Total 1139.000000 53928.7500 47.3475
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 201
-----------------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 598 622.250000 30798.5000 0.0000
P 5 13.000000 170.0000 170.0000
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
428 495.250000 22645.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1041 1139.000000 53928.7500 170.0000