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
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 146 465.750000 17232.7500 37.0000
Subtotal (Total Children Is Unduplicated) 146 465.750000 17232.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 67.000000 5025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 48.000000 3600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 47.000000 2608.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 38.000000 2850.0000 75.0000
Subtotal (Total Children Is Unduplicated) 69 211.000000 14908.5000 70.6564
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 1 1.000000 71.4400 71.4400
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Total 677.750000 32212.6900 47.5289
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Number of Children (Unduplicated) With at Least One Service 148
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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 420 522.750000 23027.7500 23018.0000
D 0 0.000000 0.0000 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
59 115.000000 7704.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 524 677.750000 32212.6900 23018.0000