CMS/EIP Fiscal Report Center: 04
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 71 415.000000 15355.0000 37.0000
Subtotal (Total Children Is Unduplicated) 71 415.000000 15355.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 18.000000 1350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 23.000000 1725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 53.000000 2941.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 13.500000 1012.5000 75.0000
Subtotal (Total Children Is Unduplicated) 63 107.500000 7029.0000 65.3860
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Total 522.500000 22384.0000 42.8402
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Number of Children (Unduplicated) With at Least One Service 74
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Center 04
Flag Claims Units Chgs Paid
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R 18 39.250000 1452.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 68 112.750000 4962.7500 0.0000
P 209 352.000000 14757.0000 14646.0000
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
25 18.500000 1212.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 320 522.500000 22384.0000 14646.0000