CMS/EIP Fiscal Report Center: 53
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 68 287.500000 10489.5000 36.4852
Subtotal (Total Children Is Unduplicated) 68 287.500000 10489.5000 36.4852
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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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.000000 975.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 48.500000 2636.2500 54.3557
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 61.500000 4612.5000 75.0000
Subtotal (Total Children Is Unduplicated) 45 137.500000 9155.2500 66.5836
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 7.000000 350.0000 50.0000
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Total 432.000000 19994.7500 46.2841
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Number of Children (Unduplicated) With at Least One Service 69
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Center 53
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 149 166.750000 7144.5000 0.0000
P 151 162.250000 7658.5000 7658.5000
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
81 103.000000 5191.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 381 432.000000 19994.7500 7658.5000