CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 85 238.750000 8833.7500 37.0000
Subtotal (Total Children Is Unduplicated) 85 238.750000 8833.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 57.000000 4230.0000 74.2105
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 33.500000 2512.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 28.500000 2137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 53 75.000000 4134.7500 55.1300
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 43.000000 3187.5000 74.1279
Subtotal (Total Children Is Unduplicated) 92 248.500000 16986.7500 68.3571
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Total 487.250000 25820.5000 52.9923
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Number of Children (Unduplicated) With at Least One Service 97
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Center 09
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 6 9.000000 519.0000 0.0000
P 332 478.250000 25301.5000 25301.5000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 338 487.250000 25820.5000 25301.5000