CMS/EIP Fiscal Report Center: 05
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 611 1601.500000 59200.0000 36.9653
Subtotal (Total Children Is Unduplicated) 611 1601.500000 59200.0000 36.9653
-----------------------------------------------------------------------------------------------------------------------
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 3 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 61.000000 4575.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 39.000000 2925.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 44.500000 3337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 78 151.000000 11325.0000 75.0000
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 38.750000 1937.5000 50.0000
Subtotal (Total Children Is Unduplicated) 8 38.750000 1937.5000 50.0000
-----------------------------------------------------------------------------------------------------------------------
Total 1791.250000 72462.5000 40.4536
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 611
-----------------------------------------------------------------------------------------------------------------------
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2793 1788.250000 72312.5000 0.0000
P 3 3.000000 150.0000 150.0000
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
---------------------------------------------------------
Total 2796 1791.250000 72462.5000 150.0000