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:TPIN
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 1 8.250000 305.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 8.250000 305.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 9.500000 712.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 23.500000 1304.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 14.500000 1087.5000 75.0000
Subtotal (Total Children Is Unduplicated) 19 56.500000 3779.2500 66.8894
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Total 64.750000 4084.5000 63.0811
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Number of Children (Unduplicated) With at Least One Service 19
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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 0 0.000000 0.0000 0.0000
P 2 4.000000 261.0000 324.2600
D 2 3.000000 195.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.500000 158.2500 158.2500
T 0 0.000000 0.0000 0.0000
34 53.750000 3357.0000 0.0000
Other 1 1.500000 112.5000 0.0000
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Total 41 64.750000 4084.5000 482.5100