CMS/EIP Fiscal Report Center: 57
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 823 2943.250000 108900.2500 37.0000
Subtotal (Total Children Is Unduplicated) 823 2943.250000 108900.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 133 126.500000 9487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 132 130.500000 7242.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 53.500000 4012.5000 75.0000
Subtotal (Total Children Is Unduplicated) 165 323.500000 21600.7500 66.7720
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 50.0000 50.0000
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Total 3267.750000 130551.0000 39.9513
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Number of Children (Unduplicated) With at Least One Service 824
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Center 57
Flag Claims Units Chgs Paid
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R 6 6.750000 249.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3322 3231.500000 128801.2500 0.0000
P 1 1.500000 55.5000 55.5000
D 8 7.750000 343.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 15 18.500000 1023.5000 0.0000
T 0 0.000000 0.0000 0.0000
2 1.750000 77.7500 50.0000
Other 0 0.000000 0.0000 0.0000
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Total 3354 3267.750000 130551.0000 105.5000