CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2016 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 161 855.250000 31505.5000 36.8378
Subtotal (Total Children Is Unduplicated) 161 855.250000 31505.5000 36.8378
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
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 9 13.500000 1012.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 21.500000 1193.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 31.500000 2362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 104 159.500000 8852.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 118 193.500000 14512.5000 75.0000
Subtotal (Total Children Is Unduplicated) 147 438.000000 29320.5000 66.9418
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 13.000000 650.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 13.000000 650.0000 50.0000
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Total 1306.250000 61476.0000 47.0630
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Number of Children (Unduplicated) With at Least One Service 161
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Center 53
Flag Claims Units Chgs Paid
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R 8 7.250000 268.2500 129.5000
U 0 0.000000 0.0000 0.0000
B 89 92.000000 4570.0000 453.2500
P 916 1027.500000 47071.2500 47071.2500
D 0 0.000000 0.0000 0.0000
S 63 67.250000 2460.5000 2405.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
82 112.250000 7106.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1158 1306.250000 61476.0000 50059.0000