CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 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 47 207.500000 7640.5000 36.8217
Subtotal (Total Children Is Unduplicated) 47 207.500000 7640.5000 36.8217
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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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 39.500000 2192.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 48.500000 3637.5000 75.0000
Subtotal (Total Children Is Unduplicated) 42 118.000000 7894.5000 66.9025
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Total 325.500000 15535.0000 47.7266
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Number of Children (Unduplicated) With at Least One Service 49
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Center 53
Flag Claims Units Chgs Paid
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R 1 2.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 64 69.250000 3431.7500 0.0000
P 152 183.750000 8602.5000 8602.5000
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 1 1.000000 37.0000 0.0000
58 69.500000 3352.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 276 325.500000 15535.0000 8602.5000