CMS/EIP Fiscal Report Center: 03
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 116 243.500000 9009.5000 37.0000
Subtotal (Total Children Is Unduplicated) 116 243.500000 9009.5000 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
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 26.500000 1987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 24.000000 1800.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 26.000000 1950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 8.500000 471.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
Subtotal (Total Children Is Unduplicated) 34 96.500000 7071.7500 73.2824
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Total 340.000000 16081.2500 47.2978
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Number of Children (Unduplicated) With at Least One Service 121
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Center 03
Flag Claims Units Chgs Paid
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R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 41 53.750000 3745.0000 37.0000
P 315 280.500000 12123.5000 12048.0000
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
15 5.000000 185.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 372 340.000000 16081.2500 12085.0000