CMS/EIP Fiscal Report Center: 04
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 79 463.250000 17140.2500 37.0000
Subtotal (Total Children Is Unduplicated) 79 463.250000 17140.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 17.500000 1312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 20.500000 1537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 56.000000 3108.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 27.000000 2025.0000 75.0000
Subtotal (Total Children Is Unduplicated) 69 122.500000 8076.0000 65.9265
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Total 585.750000 25216.2500 43.0495
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Number of Children (Unduplicated) With at Least One Service 84
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Center 04
Flag Claims Units Chgs Paid
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R 36 72.000000 2664.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 61 105.750000 4590.7500 0.0000
P 242 384.500000 16442.7500 16648.7500
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
33 23.500000 1518.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 372 585.750000 25216.2500 16648.7500