CMS/EIP Fiscal Report Center: 10
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 124 451.750000 16714.7500 37.0000
Subtotal (Total Children Is Unduplicated) 124 451.750000 16714.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 64.000000 4800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 28.000000 2100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 53 89.500000 4967.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 67 217.000000 14490.7500 66.7777
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Total 668.750000 31205.5000 46.6624
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Number of Children (Unduplicated) With at Least One Service 126
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Center 10
Flag Claims Units Chgs Paid
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R 4 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 611 650.500000 30530.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 14 13.000000 481.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 2.000000 74.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 630 668.750000 31205.5000 0.0000