CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 56 217.500000 8047.5000 37.0000
Subtotal (Total Children Is Unduplicated) 56 217.500000 8047.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.000000 525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 16.500000 915.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 7.500000 562.5000 75.0000
Subtotal (Total Children Is Unduplicated) 27 56.500000 3876.7500 68.6150
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Total 274.000000 11924.2500 43.5192
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Number of Children (Unduplicated) With at Least One Service 56
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Center 01
Flag Claims Units Chgs Paid
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R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 261 240.750000 9711.5000 0.0000
P 2 2.500000 158.2500 158.2500
D 0 0.000000 0.0000 0.0000
S 6 4.000000 262.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
12 13.250000 916.5000 0.0000
Other 8 11.500000 726.0000 0.0000
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Total 290 274.000000 11924.2500 158.2500