CMS/EIP Fiscal Report Center: 54
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 113 506.750000 18731.2500 36.9635
Subtotal (Total Children Is Unduplicated) 113 506.750000 18731.2500 36.9635
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.000000 825.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 11.000000 825.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 50.300000 3772.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 35.000000 2625.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 54 74.500000 4134.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 35.500000 2662.5000 75.0000
Subtotal (Total Children Is Unduplicated) 94 254.300000 17327.2500 68.1370
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Total 761.050000 36058.5000 47.3799
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Number of Children (Unduplicated) With at Least One Service 114
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Center 54
Flag Claims Units Chgs Paid
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R 4 6.750000 249.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 313 327.250000 15200.7500 37.0000
P 293 297.000000 13229.5000 13229.5000
D 4 5.500000 383.2500 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
72 101.550000 6144.2500 0.0000
Other 25 23.000000 851.0000 0.0000
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Total 711 761.050000 36058.5000 13266.5000