CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 2 1.250000 46.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 33.750000 1248.7500 37.0000
Subtotal (Total Children Is Unduplicated) 12 35.000000 1295.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 19.500000 1462.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 14.500000 804.7500 55.5000
Subtotal (Total Children Is Unduplicated) 17 42.000000 2867.2500 68.2679
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Total 77.000000 4162.2500 54.0552
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Number of Children (Unduplicated) With at Least One Service 20
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Center 06
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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
83 77.000000 4162.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 83 77.000000 4162.2500 0.0000