CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 61 259.000000 9583.0000 37.0000
Subtotal (Total Children Is Unduplicated) 61 259.000000 9583.0000 37.0000
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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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 23.000000 1725.0000 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 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 63.500000 3524.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 41.500000 3112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 48 140.500000 9231.0000 65.7011
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Total 399.500000 18814.0000 47.0939
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Number of Children (Unduplicated) With at Least One Service 61
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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 1 0.500000 18.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 99 112.500000 5087.5000 0.0000
H 248 225.500000 9835.0000 9835.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 39 61.000000 3873.0000 0.0000
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Total 387 399.500000 18814.0000 9835.0000