CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:DEI Only
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 7.500000 277.5000 37.0000
Subtotal (Total Children Is Unduplicated) 2 7.500000 277.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 0.500000 27.7500 55.5000
Subtotal (Total Children Is Unduplicated) 1 1.500000 102.7500 68.5000
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Total 9.000000 380.2500 42.2500
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Number of Children (Unduplicated) With at Least One Service 2
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Center 04
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 4 7.500000 277.5000 277.5000
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
2 1.500000 102.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6 9.000000 380.2500 277.5000