CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 1.250000 46.2500 37.0000
Subtotal (Total Children Is Unduplicated) 3 1.500000 55.5000 37.0000
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Screening, Eval, and Assessment,Class #02
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 23 55.000000 3505.0500 63.7282
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 29.500000 2212.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 17.000000 1160.2900 68.2524
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 52.000000 2875.6500 55.3010
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 30 160.500000 10219.9900 63.6760
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Total 162.000000 10275.4900 63.4290
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Number of Children (Unduplicated) With at Least One Service 32
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Center 52
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 0 0.000000 0.0000 0.0000
P 6 12.000000 783.0000 375.2800
D 1 2.000000 111.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 23 43.500000 2862.7500 0.0000
T 30 59.000000 3692.8200 3652.8200
26 45.500000 2825.9200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 86 162.000000 10275.4900 4028.1000