CMS/EIP Fiscal Report Center: 54
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 129 529.250000 19517.5000 36.8777
Subtotal (Total Children Is Unduplicated) 129 529.250000 19517.5000 36.8777
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 20.500000 1137.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 70 98.500000 7387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 28.500000 2137.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 79 109.000000 6049.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 27.500000 2062.5000 75.0000
Subtotal (Total Children Is Unduplicated) 113 314.500000 21062.2500 66.9706
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Total 843.750000 40579.7500 48.0945
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Number of Children (Unduplicated) With at Least One Service 131
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Center 54
Flag Claims Units Chgs Paid
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R 150 156.750000 6852.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 333 317.250000 15207.5000 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
309 369.750000 18520.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 792 843.750000 40579.7500 0.0000