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: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 911 2236.750000 82759.7500 37.0000
Subtotal (Total Children Is Unduplicated) 911 2236.750000 82759.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 100 150.000000 11250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 67 101.500000 7612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 84 128.500000 7131.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 29.500000 2212.5000 75.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
Subtotal (Total Children Is Unduplicated) 139 423.500000 29094.5400 68.7002
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Total 2660.250000 111854.2900 42.0465
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Number of Children (Unduplicated) With at Least One Service 911
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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
4034 2660.250000 111854.2900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4034 2660.250000 111854.2900 0.0000