CMS/EIP Fiscal Report Center: 09
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 74 248.500000 9194.5000 37.0000
Subtotal (Total Children Is Unduplicated) 74 248.500000 9194.5000 37.0000
-----------------------------------------------------------------------------------------------------------------------
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 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
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 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 53.500000 4012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 8.500000 637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 59.000000 4425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 80.500000 4467.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 30.000000 2250.0000 75.0000
Subtotal (Total Children Is Unduplicated) 74 241.500000 16503.7500 68.3385
-----------------------------------------------------------------------------------------------------------------------
Total 490.000000 25698.2500 52.4454
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 77
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 18.500000 684.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 76 135.000000 6259.0000 0.0000
P 134 229.500000 10856.5000 10856.5600
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
6 8.500000 598.5000 0.0000
Other 65 98.500000 7299.7500 0.0000
---------------------------------------------------------
Total 294 490.000000 25698.2500 10856.5600