CMS/EIP Fiscal Report Center: 03
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 66 221.500000 8195.5000 37.0000
Subtotal (Total Children Is Unduplicated) 66 221.500000 8195.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 27.000000 2025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 22.000000 1221.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 11.000000 825.0000 75.0000
SCREEN-T1023-SCREENING 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 26 81.500000 5633.5000 69.1227
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Total 303.000000 13829.0000 45.6403
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Number of Children (Unduplicated) With at Least One Service 66
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Center 03
Flag Claims Units Chgs Paid
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R 7 6.250000 231.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 297 296.750000 13597.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 304 303.000000 13829.0000 0.0000