CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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 72 313.750000 11553.2500 36.8231
Subtotal (Total Children Is Unduplicated) 72 313.750000 11553.2500 36.8231
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 54.000000 2997.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 86.000000 6450.0000 75.0000
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 50 144.000000 9647.0000 66.9931
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Total 457.750000 21200.2500 46.3140
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Number of Children (Unduplicated) With at Least One Service 76
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Center 07
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 1 1.500000 55.5000 0.0000
P 423 456.250000 21144.7500 21144.7500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 424 457.750000 21200.2500 21144.7500