CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 485 1316.250000 48571.7500 36.9016
Subtotal (Total Children Is Unduplicated) 485 1316.250000 48571.7500 36.9016
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 64 96.000000 7200.0000 75.0000
Subtotal (Total Children Is Unduplicated) 67 100.500000 7537.5000 75.0000
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Total 1416.750000 56109.2500 39.6042
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Number of Children (Unduplicated) With at Least One Service 487
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Center 55
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 4 3.000000 111.0000 0.0000
P 1463 1413.750000 55998.2500 55995.2500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1467 1416.750000 56109.2500 55995.2500