CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 72 195.000000 7215.0000 37.0000
Subtotal (Total Children Is Unduplicated) 72 195.000000 7215.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 36.000000 2700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 24.000000 1800.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 35.000000 2625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 59.000000 3274.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 31.500000 2362.5000 75.0000
Subtotal (Total Children Is Unduplicated) 73 196.000000 13500.7500 68.8814
-----------------------------------------------------------------------------------------------------------------------
Total 391.000000 20715.7500 52.9815
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 77
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 17.500000 818.5000 0.0000
P 220 321.500000 16046.0000 16046.0000
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
1 1.000000 75.0000 0.0000
Other 41 51.000000 3776.2500 0.0000
---------------------------------------------------------
Total 271 391.000000 20715.7500 16046.0000