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:TPIN
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 5 27.500000 1017.5000 37.0000
Subtotal (Total Children Is Unduplicated) 5 27.500000 1017.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 13.500000 749.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 15.500000 1162.5000 75.0000
Subtotal (Total Children Is Unduplicated) 13 36.000000 2436.7500 67.6875
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Total 63.500000 3454.2500 54.3976
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Number of Children (Unduplicated) With at Least One Service 14
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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 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
41 63.500000 3454.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 41 63.500000 3454.2500 0.0000