CMS/EIP Fiscal Report Center: 57
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 27 119.500000 4421.5000 37.0000
Subtotal (Total Children Is Unduplicated) 27 119.500000 4421.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 17.500000 1312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 27.000000 1498.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 11.500000 862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 27 56.000000 3673.5000 65.5982
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Total 175.500000 8095.0000 46.1254
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Number of Children (Unduplicated) With at Least One Service 29
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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 94 119.000000 5722.0000 0.0000
P 31 46.500000 1720.5000 1720.5000
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
6 10.000000 652.5000 522.0000
Other 0 0.000000 0.0000 0.0000
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Total 131 175.500000 8095.0000 2242.5000