CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 769 1807.000000 66859.0000 37.0000
Subtotal (Total Children Is Unduplicated) 769 1807.000000 66859.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 95.500000 7162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 36.000000 2700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 37.000000 2775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 28.500000 1581.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.000000 750.0000 75.0000
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 76 219.000000 15735.7500 71.8527
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 4 5.000000 250.0000 50.0000
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Total 2031.000000 82844.7500 40.7901
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Number of Children (Unduplicated) With at Least One Service 777
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Center 03
Flag Claims Units Chgs Paid
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R 26 30.750000 1488.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3053 2000.250000 81356.2500 0.0000
P 0 0.000000 0.0000 0.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3079 2031.000000 82844.7500 0.0000