CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 94 411.000000 15197.7500 36.9775
Subtotal (Total Children Is Unduplicated) 94 411.000000 15197.7500 36.9775
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 68.500000 3801.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 96.500000 7237.5000 75.0000
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 65 199.500000 13316.5000 66.7494
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Total 610.500000 28514.2500 46.7064
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Number of Children (Unduplicated) With at Least One Service 94
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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 15 13.000000 481.0000 0.0000
P 555 594.500000 27846.2500 27846.2500
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
3 3.000000 187.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 573 610.500000 28514.2500 27846.2500