CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:TPIN
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 4 8.250000 305.2500 37.0000
Subtotal (Total Children Is Unduplicated) 4 8.250000 305.2500 37.0000
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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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 21.500000 1382.1700 64.2870
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 904.6700 64.6193
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 835.2600 59.6614
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 41.000000 2275.5000 55.5000
Subtotal (Total Children Is Unduplicated) 24 92.500000 5547.6000 59.9741
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Total 100.750000 5852.8500 58.0928
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Number of Children (Unduplicated) With at Least One Service 24
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Center 52
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 8 15.500000 701.2600 568.4700
D 6 11.000000 649.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
38 72.250000 4352.0900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 53 100.750000 5852.8500 568.4700