CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 72 345.750000 12710.5000 36.7621
Subtotal (Total Children Is Unduplicated) 72 345.750000 12710.5000 36.7621
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Screening, Eval, and Assessment,Class #02
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 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 17.500000 1312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 22.500000 1248.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 15.500000 1162.5000 75.0000
Subtotal (Total Children Is Unduplicated) 31 74.500000 5129.2500 68.8490
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Total 420.250000 17839.7500 42.4503
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Number of Children (Unduplicated) With at Least One Service 72
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Center 01
Flag Claims Units Chgs Paid
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R 3 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 362 282.000000 10455.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 25 38.000000 2440.5000 0.0000
S 80 95.250000 4740.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 3.500000 148.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 474 420.250000 17839.7500 0.0000