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
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 40 145.750000 5392.7500 37.0000
Subtotal (Total Children Is Unduplicated) 40 145.750000 5392.7500 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-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 10 14.500000 1087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 8.500000 637.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 12.500000 937.5000 75.0000
Subtotal (Total Children Is Unduplicated) 19 38.500000 2887.5000 75.0000
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Total 184.250000 8280.2500 44.9403
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Number of Children (Unduplicated) With at Least One Service 40
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Center 05
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 218 184.000000 8271.0000 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
1 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 219 184.250000 8280.2500 0.0000