CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 591 967.000000 35707.0000 36.9255
Subtotal (Total Children Is Unduplicated) 591 967.000000 35707.0000 36.9255
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 46.000000 3450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 86.000000 6450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 73.500000 4079.2500 55.5000
Subtotal (Total Children Is Unduplicated) 84 218.000000 14780.2500 67.7993
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 54 232.250000 11612.5000 50.0000
Subtotal (Total Children Is Unduplicated) 54 232.250000 11612.5000 50.0000
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Total 1417.250000 62099.7500 43.8171
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Number of Children (Unduplicated) With at Least One Service 614
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Center 02
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 0 0.000000 0.0000 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
0 0.000000 0.0000 0.0000
Other 1877 1417.250000 62099.7500 0.0000
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Total 1877 1417.250000 62099.7500 0.0000