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
Agency Filter:EIP DEI DEIP
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 1966 5884.500000 217719.2500 36.9988
Subtotal (Total Children Is Unduplicated) 1966 5884.500000 217719.2500 36.9988
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 202 369.000000 27675.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 102 179.500000 13462.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 51 81.500000 6112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 202 367.000000 20368.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 99 126.500000 9487.5000 75.0000
Subtotal (Total Children Is Unduplicated) 329 1164.500000 79986.0000 68.6870
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 3.000000 150.0000 50.0000
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Total 7052.000000 297855.2500 42.2370
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Number of Children (Unduplicated) With at Least One Service 1974
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Center 10
Flag Claims Units Chgs Paid
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R 31 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8880 7014.750000 295890.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 10 17.750000 1204.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 4.500000 205.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8925 7052.000000 297855.2500 0.0000