CMS/EIP Fiscal Report Center: 53
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 51 230.500000 8528.5000 37.0000
Subtotal (Total Children Is Unduplicated) 51 230.500000 8528.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 17.000000 1275.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 59.000000 3219.0000 54.5593
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 39.500000 2962.5000 75.0000
Subtotal (Total Children Is Unduplicated) 45 137.000000 8952.0000 65.3431
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 5.000000 250.0000 50.0000
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Total 372.500000 17730.5000 47.5987
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Number of Children (Unduplicated) With at Least One Service 57
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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 64 73.500000 3176.7500 27.7500
P 202 242.000000 11417.7500 11417.7500
D 0 0.000000 0.0000 0.0000
S 2 1.500000 55.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
44 55.500000 3080.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 312 372.500000 17730.5000 11445.5000