CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2019 ending 06/30/2019 Date of Report:07/21/2019 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 60 252.250000 9314.7500 36.9267
Subtotal (Total Children Is Unduplicated) 60 252.250000 9314.7500 36.9267
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 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 10 15.500000 1162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 13.500000 1012.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 14.500000 1087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 71.000000 3940.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 42.500000 3187.5000 75.0000
Subtotal (Total Children Is Unduplicated) 57 163.000000 10801.5000 66.2669
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Total 415.250000 20116.2500 48.4437
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Number of Children (Unduplicated) With at Least One Service 61
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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 214 234.250000 10931.2500 0.0000
P 105 126.250000 5934.7500 5934.7500
D 0 0.000000 0.0000 0.0000
S 6 7.000000 240.5000 240.5000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
32 47.750000 3009.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 357 415.250000 20116.2500 6175.2500