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:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 2.250000 83.2500 37.0000
Subtotal (Total Children Is Unduplicated) 3 3.500000 83.2500 23.7857
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 29.500000 2113.9600 71.6597
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 35.000000 1886.2100 53.8917
Subtotal (Total Children Is Unduplicated) 23 72.500000 4600.1700 63.4506
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Total 76.000000 4683.4200 61.6239
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Number of Children (Unduplicated) With at Least One Service 24
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Center 52
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 1 2.000000 54.7100 54.7100
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 16 31.000000 2061.7500 1766.2700
26 43.000000 2566.9600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 43 76.000000 4683.4200 1820.9800