CMS/EIP Fiscal Report Center: 09
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 71 229.500000 8417.5000 36.6776
Subtotal (Total Children Is Unduplicated) 71 229.500000 8417.5000 36.6776
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 38.500000 2887.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 30.000000 2250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 39.000000 2886.0000 74.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 74.500000 4134.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 35.000000 2625.0000 75.0000
Subtotal (Total Children Is Unduplicated) 71 237.000000 16127.2500 68.0475
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Total 466.500000 24544.7500 52.6147
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Number of Children (Unduplicated) With at Least One Service 73
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Center 09
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 11 17.250000 713.2500 0.0000
P 204 348.750000 16508.5000 16508.5000
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 111.0000 166.5000
4 7.000000 525.0000 0.0000
Other 54 89.500000 6537.0000 0.0000
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Total 275 466.500000 24544.7500 16675.0000