CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2015 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 186 967.250000 35658.7500 36.8661
Subtotal (Total Children Is Unduplicated) 186 967.250000 35658.7500 36.8661
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 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 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 17.000000 888.0000 52.2353
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 35.500000 2662.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 119 198.000000 11044.5000 55.7803
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 146 235.000000 17737.5000 75.4787
Subtotal (Total Children Is Unduplicated) 178 530.500000 35707.5000 67.3091
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 48.750000 2437.5000 50.0000
Subtotal (Total Children Is Unduplicated) 7 48.750000 2437.5000 50.0000
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Total 1546.500000 73803.7500 47.7231
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Number of Children (Unduplicated) With at Least One Service 201
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Center 53
Flag Claims Units Chgs Paid
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R 41 34.500000 1276.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 270 305.500000 14927.2500 0.0000
P 855 931.000000 41644.2500 41644.2500
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
201 275.500000 15955.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1367 1546.500000 73803.7500 41644.2500