CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 23 37.750000 1396.7500 37.0000
Subtotal (Total Children Is Unduplicated) 23 37.750000 1396.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 150.0000 75.0000
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Total 39.750000 1546.7500 38.9119
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Number of Children (Unduplicated) With at Least One Service 23
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Center 04
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 38 26.000000 962.0000 0.0000
P 10 11.750000 434.7500 434.7500
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
2 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 50 39.750000 1546.7500 434.7500