CMS/EIP Fiscal Report Center: 55
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
CASE-CASE-NON-TCM CASE MANAGEMENT 143 246.500000 9120.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 15.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 164 537.250000 19878.2500 37.0000
Subtotal (Total Children Is Unduplicated) 171 799.500000 28998.7500 36.2711
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 82.500703 6187.5002 74.9994
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 23.000000 1725.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 58.000000 4350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 52.500000 2913.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 40.000000 3000.0000 75.0000
Subtotal (Total Children Is Unduplicated) 83 260.000703 18476.2502 71.0623
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EI Services,Class #03
INTR-T1013-INTERPRETER 1 2.000000 114.0000 57.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 2 4.000000 195.4400 48.8600
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Total 1063.500703 47670.4402 44.8241
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Number of Children (Unduplicated) With at Least One Service 172
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Center 55
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 22 28.000000 1036.0000 0.0000
P 435 547.454737 24672.3602 24662.6100
D 2 1.000000 37.0000 0.0000
S 23 12.000000 444.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
571 475.045966 21481.0800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1053 1063.500703 47670.4402 24662.6100