CMS/EIP Fiscal Report Center: 06
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 37 125.750000 4652.7500 37.0000
Subtotal (Total Children Is Unduplicated) 37 125.750000 4652.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 25.500000 1912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 31.000000 1720.5000 55.5000
Subtotal (Total Children Is Unduplicated) 27 68.000000 4495.5000 66.1103
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Total 193.750000 9148.2500 47.2168
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Number of Children (Unduplicated) With at Least One Service 38
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Center 06
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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
178 193.750000 9148.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 178 193.750000 9148.2500 0.0000