CMS/EIP Fiscal Report Center: 57
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 15 54.250000 2007.2500 37.0000
Subtotal (Total Children Is Unduplicated) 15 54.250000 2007.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 7.000000 525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 22.500000 1248.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 20 44.500000 2898.7500 65.1404
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Total 98.750000 4906.0000 49.6810
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Number of Children (Unduplicated) With at Least One Service 23
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Center 57
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 63 80.250000 3741.2500 0.0000
P 5 6.500000 381.7500 381.7500
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
6 12.000000 783.0000 783.0000
Other 0 0.000000 0.0000 0.0000
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Total 74 98.750000 4906.0000 1164.7500