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
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 693 2192.750000 81122.5000 36.9958
Subtotal (Total Children Is Unduplicated) 693 2192.750000 81122.5000 36.9958
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 86 171.500000 12862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 89 177.500000 13312.5000 75.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 225.500000 11275.0000 50.0000
Subtotal (Total Children Is Unduplicated) 42 225.500000 11275.0000 50.0000
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Total 2595.750000 105710.0000 40.7243
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Number of Children (Unduplicated) With at Least One Service 694
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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 21 15.000000 555.0000 0.0000
P 2861 2580.000000 105127.2500 105127.2500
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
1 0.750000 27.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2883 2595.750000 105710.0000 105127.2500