CMS/EIP Fiscal Report Center: 53
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 71 256.500000 9490.5000 37.0000
Subtotal (Total Children Is Unduplicated) 71 256.500000 9490.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 5.000000 277.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 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 55 87.500000 4856.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 87.000000 6525.0000 75.0000
Subtotal (Total Children Is Unduplicated) 64 195.000000 12821.2500 65.7500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 12.000000 600.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 12.000000 600.0000 50.0000
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Total 463.500000 22911.7500 49.4320
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Number of Children (Unduplicated) With at Least One Service 78
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Center 53
Flag Claims Units Chgs Paid
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R 101 102.250000 4699.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 22.000000 898.7500 0.0000
P 122 154.750000 7822.2500 7822.2500
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
152 184.250000 9482.5000 0.0000
Other 1 0.250000 9.2500 0.0000
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Total 400 463.500000 22911.7500 7822.2500