CMS/EIP Fiscal Report Center: 55
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 96 403.250000 14920.2500 37.0000
Subtotal (Total Children Is Unduplicated) 96 403.250000 14920.2500 37.0000
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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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 96.000000 7200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 60.500000 4537.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 36.000000 2700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.000000 1110.0000 55.5000
Subtotal (Total Children Is Unduplicated) 64 224.500000 16408.5000 73.0891
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EI Services,Class #03
PHY-97110HM-PT SESSION BY PT ASST 2 13.000000 743.0800 57.1600
Subtotal (Total Children Is Unduplicated) 2 13.000000 743.0800 57.1600
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Total 640.750000 32071.8300 50.0536
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Number of Children (Unduplicated) With at Least One Service 96
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Center 55
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 1 0.500000 18.5000 0.0000
P 395 498.750000 22177.7500 22177.7500
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
92 141.500000 9875.5800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 488 640.750000 32071.8300 22177.7500