CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 32 105.500000 3903.5000 37.0000
Subtotal (Total Children Is Unduplicated) 32 105.500000 3903.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.000000 1110.0000 55.5000
Subtotal (Total Children Is Unduplicated) 11 20.000000 1110.0000 55.5000
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Total 125.500000 5013.5000 39.9482
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Number of Children (Unduplicated) With at Least One Service 32
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Center 02
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 2.000000 111.0000 0.0000
Other 128 123.500000 4902.5000 0.0000
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Total 129 125.500000 5013.5000 0.0000