CMS/EIP Fiscal Report Center: 52
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 57 216.250000 7992.0000 36.9572
Subtotal (Total Children Is Unduplicated) 57 216.250000 7992.0000 36.9572
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 48.500000 3637.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 18.000000 1350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 70.500000 3912.7500 55.5000
Subtotal (Total Children Is Unduplicated) 42 147.000000 9650.2500 65.6480
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Total 363.250000 17642.2500 48.5678
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Number of Children (Unduplicated) With at Least One Service 57
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Center 52
Flag Claims Units Chgs Paid
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R 6 12.000000 900.0000 220.0000
U 0 0.000000 0.0000 0.0000
B 179 222.500000 10952.5000 1677.5000
P 107 101.750000 3764.7500 3764.7500
D 0 0.000000 0.0000 0.0000
S 1 2.000000 150.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
13 25.000000 1875.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 306 363.250000 17642.2500 5662.2500