CMS/EIP Fiscal Report Center: 53
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 57 247.000000 9139.0000 37.0000
Subtotal (Total Children Is Unduplicated) 57 247.000000 9139.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 33.500000 1859.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 52.000000 3900.0000 75.0000
Subtotal (Total Children Is Unduplicated) 43 108.500000 7357.5000 67.8111
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Total 355.500000 16496.5000 46.4037
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Number of Children (Unduplicated) With at Least One Service 57
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Center 53
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 293 308.250000 14113.5000 14113.5000
D 0 0.000000 0.0000 0.0000
S 29 28.750000 1063.7500 1008.2500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
13 18.500000 1319.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 335 355.500000 16496.5000 15121.7500