CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 98 388.500000 14374.5000 37.0000
Subtotal (Total Children Is Unduplicated) 98 388.500000 14374.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 65 130.000000 9750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 36.000000 2700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 32.000000 1776.0000 55.5000
Subtotal (Total Children Is Unduplicated) 78 242.000000 17526.0000 72.4215
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 11.000000 550.0000 50.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 357.2000 71.4400
Subtotal (Total Children Is Unduplicated) 2 16.000000 907.2000 56.7000
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Total 646.500000 32807.7000 50.7466
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Number of Children (Unduplicated) With at Least One Service 99
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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 9 10.500000 388.5000 0.0000
P 379 504.000000 23436.0000 23436.0000
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
74 132.000000 8983.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 462 646.500000 32807.7000 23436.0000