CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 59 205.250000 7594.2500 37.0000
Subtotal (Total Children Is Unduplicated) 59 205.250000 7594.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 36.000000 1998.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 45.000000 3375.0000 75.0000
Subtotal (Total Children Is Unduplicated) 35 91.500000 6102.0000 66.6885
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Total 296.750000 13696.2500 46.1542
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Number of Children (Unduplicated) With at Least One Service 59
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Center 01
Flag Claims Units Chgs Paid
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R 15 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 44 53.250000 3800.0000 0.0000
P 239 195.000000 7215.0000 7215.0000
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
1 0.500000 18.5000 0.0000
Other 29 39.500000 2348.2500 0.0000
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Total 328 296.750000 13696.2500 7215.0000