CMS/EIP Fiscal Report Center: 07
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 59 218.750000 8093.7500 37.0000
Subtotal (Total Children Is Unduplicated) 59 218.750000 8093.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 32.500000 2437.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 38.000000 2109.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 29.500000 2212.5000 75.0000
Subtotal (Total Children Is Unduplicated) 35 112.000000 7542.0000 67.3393
-----------------------------------------------------------------------------------------------------------------------
Total 330.750000 15635.7500 47.2736
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 59
-----------------------------------------------------------------------------------------------------------------------
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.500000 18.5000 0.0000
P 273 327.500000 15515.5000 15515.5000
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
4 2.750000 101.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 278 330.750000 15635.7500 15515.5000