CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 ending 09/30/2016 Date of Report:10/31/2016 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 45 87.000000 3163.5000 36.3621
Subtotal (Total Children Is Unduplicated) 45 87.000000 3163.5000 36.3621
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 5.000000 375.0000 75.0000
Subtotal (Total Children Is Unduplicated) 5 5.000000 375.0000 75.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 8.000000 400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 5 8.000000 400.0000 50.0000
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Total 100.000000 3938.5000 39.3850
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Number of Children (Unduplicated) With at Least One Service 55
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Center 53
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 126 100.000000 3938.5000 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 126 100.000000 3938.5000 0.0000