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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 569 1455.750000 53807.2500 36.9619
Subtotal (Total Children Is Unduplicated) 569 1455.750000 53807.2500 36.9619
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 46.500000 3487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 27 30.500000 2287.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 32.000000 2400.0000 75.0000
Subtotal (Total Children Is Unduplicated) 59 112.500000 8437.5000 75.0000
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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
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Total 1607.000000 64182.2500 39.9392
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Number of Children (Unduplicated) With at Least One Service 569
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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 2573 1603.250000 64004.5000 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
2 0.750000 27.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2578 1607.000000 64182.2500 150.0000