CMS/EIP Fiscal Report Center: 10
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 140 385.000000 14245.0000 37.0000
Subtotal (Total Children Is Unduplicated) 140 385.000000 14245.0000 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 50 86.000000 6450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 42.000000 3150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 86.500000 4800.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 17.500000 1312.5000 75.0000
Subtotal (Total Children Is Unduplicated) 76 249.000000 16988.2500 68.2259
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 11.000000 550.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 11.000000 550.0000 50.0000
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Total 645.000000 31783.2500 49.2764
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Number of Children (Unduplicated) With at Least One Service 141
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Center 10
Flag Claims Units Chgs Paid
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R 10 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 598 622.250000 30798.5000 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
4 14.250000 670.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 612 645.000000 31783.2500 0.0000