CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2019 ending 03/31/2019 Date of Report:05/04/2019 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 67 252.500000 9342.5000 37.0000
Subtotal (Total Children Is Unduplicated) 67 252.500000 9342.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 16.000000 1125.0000 70.3125
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 44.500000 2414.2500 54.2528
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 60.500000 4537.5000 75.0000
Subtotal (Total Children Is Unduplicated) 54 138.000000 9283.5000 67.2717
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Total 390.500000 18626.0000 47.6978
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Number of Children (Unduplicated) With at Least One Service 73
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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 110 117.000000 5472.7500 0.0000
P 181 193.750000 8948.7500 8750.6000
D 4 3.250000 138.7500 0.0000
S 8 7.750000 286.7500 286.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
60 68.750000 3779.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 363 390.500000 18626.0000 9037.3500