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
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
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 887 3030.000000 112110.0000 37.0000
Subtotal (Total Children Is Unduplicated) 887 3030.000000 112110.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 121 111.500000 8362.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 144 141.000000 7825.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 50.500000 3787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 167 319.500000 21125.2500 66.1197
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Total 3349.500000 133235.2500 39.7777
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Number of Children (Unduplicated) With at Least One Service 887
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Center 57
Flag Claims Units Chgs Paid
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R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2550 2410.500000 98379.2500 0.0000
P 914 929.750000 34513.7500 34169.5000
D 2 3.500000 129.5000 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
1 2.000000 74.0000 0.0000
Other 1 0.750000 27.7500 0.0000
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Total 3471 3349.500000 133235.2500 34169.5000