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
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 774 2380.500000 88078.5000 37.0000
Subtotal (Total Children Is Unduplicated) 774 2380.500000 88078.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 55.5000 55.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 122 99.000000 7425.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 11.500000 862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 170 153.000000 8491.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 43.500000 3262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 186 320.500000 20907.7500 65.2348
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 4.000000 285.7600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.750000 267.9000 71.4400
Subtotal (Total Children Is Unduplicated) 1 7.750000 553.6600 71.4400
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Total 2708.750000 109539.9100 40.4393
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Number of Children (Unduplicated) With at Least One Service 801
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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 2431 2486.750000 99109.7500 0.0000
P 242 207.750000 9475.2500 9475.3000
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
10 14.250000 954.9100 553.6600
Other 0 0.000000 0.0000 0.0000
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Total 2683 2708.750000 109539.9100 10028.9600