CMS/EIP Fiscal Report Center: 54
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 101 416.750000 15401.2500 36.9556
Subtotal (Total Children Is Unduplicated) 101 416.750000 15401.2500 36.9556
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 72.500000 5437.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 34.000000 2550.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 80.500000 4467.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 23.000000 1725.0000 75.0000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 87 236.000000 15963.2500 67.6409
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 2.000000 100.0000 50.0000
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Total 654.750000 31464.5000 48.0557
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Number of Children (Unduplicated) With at Least One Service 102
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Center 54
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 487 490.500000 21800.5000 0.0000
P 49 62.250000 4090.7500 4090.7500
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
83 102.000000 5573.2500 4080.5000
Other 0 0.000000 0.0000 0.0000
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Total 619 654.750000 31464.5000 8171.2500