CMS/EIP Fiscal Report Center: 57
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 40 142.750000 5281.7500 37.0000
Subtotal (Total Children Is Unduplicated) 40 142.750000 5281.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 24.500000 1359.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 17.000000 1275.0000 75.0000
Subtotal (Total Children Is Unduplicated) 24 55.000000 3647.2500 66.3136
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Total 197.750000 8929.0000 45.1530
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Number of Children (Unduplicated) With at Least One Service 40
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Center 57
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 170 177.750000 7624.0000 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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
12 20.000000 1305.0000 1344.0000
Other 0 0.000000 0.0000 0.0000
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Total 182 197.750000 8929.0000 1344.0000