CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 78 310.750000 11423.7500 36.7619
Subtotal (Total Children Is Unduplicated) 78 310.750000 11423.7500 36.7619
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 18.500000 1387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 69.000000 3829.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 62.500000 4687.5000 75.0000
Subtotal (Total Children Is Unduplicated) 60 167.500000 11090.2500 66.2104
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Total 478.250000 22514.0000 47.0758
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Number of Children (Unduplicated) With at Least One Service 78
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Center 01
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 14 18.000000 1206.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 145 147.000000 6863.7500 0.0000
H 300 262.000000 11223.5000 11223.5000
T 0 0.000000 0.0000 0.0000
1 0.250000 9.2500 0.0000
Other 35 51.000000 3210.7500 0.0000
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Total 495 478.250000 22514.0000 11223.5000