CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2017 ending 06/30/2017 Date of Report:08/05/2017 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 61 253.250000 9333.2500 36.8539
Subtotal (Total Children Is Unduplicated) 61 253.250000 9333.2500 36.8539
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.500000 487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 34 51.500000 2858.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 43 74.500000 5587.5000 75.0000
Subtotal (Total Children Is Unduplicated) 51 146.500000 9983.2500 68.1451
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 50.0000 50.0000
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Total 400.750000 19366.5000 48.3256
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Number of Children (Unduplicated) With at Least One Service 61
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Center 53
Flag Claims Units Chgs Paid
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R 2 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 33 37.000000 1989.0000 83.2500
P 271 319.000000 14699.2500 14699.2500
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
37 43.750000 2641.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 343 400.750000 19366.5000 14782.5000