CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 26 46.000000 9200.0000 200.0000
Subtotal (Total Children Is Unduplicated) 26 46.000000 9200.0000 200.0000
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Total 46.000000 9200.0000 200.0000
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Number of Children (Unduplicated) With at Least One Service 26
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Center 03
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 45 45.000000 9000.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 1.000000 200.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 46 46.000000 9200.0000 0.0000