CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2016 ending 06/30/2016 Date of Report:08/06/2016 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 61 265.250000 9814.2500 37.0000
Subtotal (Total Children Is Unduplicated) 61 265.250000 9814.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 49.500000 2747.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 53.500000 4012.5000 75.0000
Subtotal (Total Children Is Unduplicated) 46 127.500000 8529.0000 66.8941
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 9.750000 487.5000 50.0000
Subtotal (Total Children Is Unduplicated) 4 9.750000 487.5000 50.0000
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Total 402.500000 18830.7500 46.7845
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Number of Children (Unduplicated) With at Least One Service 62
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Center 53
Flag Claims Units Chgs Paid
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R 7 8.000000 296.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 100 111.250000 6265.0000 0.0000
P 162 166.250000 6609.5000 6609.5000
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
90 117.000000 5660.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 359 402.500000 18830.7500 6609.5000