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
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 584 1577.250000 58358.2500 37.0000
Subtotal (Total Children Is Unduplicated) 584 1577.250000 58358.2500 37.0000
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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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 84.000000 6300.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 44.000000 3300.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 44 131.000000 9801.0500 74.8172
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 63.000000 3150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 11 63.000000 3150.0000 50.0000
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Total 1771.250000 71309.3000 40.2593
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Number of Children (Unduplicated) With at Least One Service 587
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Center 55
Flag Claims Units Chgs Paid
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R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 149 134.750000 4985.7500 18.5000
P 1706 1554.500000 62456.5000 80327.7500
D 2 0.500000 18.5000 0.0000
S 29 16.500000 610.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
64 64.000000 3201.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1951 1771.250000 71309.3000 80346.2500