CMS/EIP Fiscal Report Center: 10
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 75 304.750000 11203.7500 36.7637
Subtotal (Total Children Is Unduplicated) 75 304.750000 11203.7500 36.7637
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 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 35 59.500000 4462.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 27.500000 2062.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 63.000000 3496.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 12.500000 937.5000 75.0000
Subtotal (Total Children Is Unduplicated) 49 172.500000 11650.5000 67.5391
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Total 477.250000 22854.2500 47.8874
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Number of Children (Unduplicated) With at Least One Service 77
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Center 10
Flag Claims Units Chgs Paid
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R 1 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 387 473.250000 22706.2500 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
1 1.250000 46.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 389 477.250000 22854.2500 0.0000