CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 ending 09/30/2018 Date of Report:11/06/2018 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 45 178.000000 6586.0000 37.0000
Subtotal (Total Children Is Unduplicated) 45 178.000000 6586.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 38.000000 2109.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 46.000000 3450.0000 75.0000
Subtotal (Total Children Is Unduplicated) 38 112.000000 7551.7500 67.4263
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Total 290.000000 14137.7500 48.7509
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Number of Children (Unduplicated) With at Least One Service 51
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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 88 98.250000 4285.5000 0.0000
P 134 157.000000 7567.5000 7567.5000
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
24 34.750000 2284.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 246 290.000000 14137.7500 7567.5000