CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 4.250000 157.2500 37.0000
Subtotal (Total Children Is Unduplicated) 4 4.250000 157.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 26.494403 1987.0804 75.0000
Subtotal (Total Children Is Unduplicated) 21 30.494403 2287.0804 75.0000
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Total 34.744403 2444.3304 70.3518
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Number of Children (Unduplicated) With at Least One Service 25
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Center 55
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 9 16.990400 1274.2800 0.0000
T 0 0.000000 0.0000 0.0000
18 17.754003 1170.0504 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 27 34.744403 2444.3304 0.0000