CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 06/30/2018 Date of Report:08/10/2018 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 205 979.250000 36232.2500 37.0000
Subtotal (Total Children Is Unduplicated) 205 979.250000 36232.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 31.500000 2362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 22.500000 1687.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 161 252.000000 13986.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 156 264.500000 19837.5000 75.0000
Subtotal (Total Children Is Unduplicated) 197 602.000000 40041.0000 66.5133
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 59.000000 2950.0000 50.0000
Subtotal (Total Children Is Unduplicated) 7 59.000000 2950.0000 50.0000
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Total 1640.250000 79223.2500 48.2995
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Number of Children (Unduplicated) With at Least One Service 219
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Center 53
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 39 31.250000 1213.2500 9.2500
P 1290 1391.250000 65171.7500 65171.7500
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
158 217.750000 12838.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1487 1640.250000 79223.2500 65181.0000