CMS/EIP Fiscal Report Center: 10
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 99 364.750000 13495.7500 37.0000
Subtotal (Total Children Is Unduplicated) 99 364.750000 13495.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 56.000000 4200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 25.500000 1912.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 58.500000 3246.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 47 165.000000 11156.2500 67.6136
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Total 529.750000 24652.0000 46.5352
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Number of Children (Unduplicated) With at Least One Service 99
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Center 10
Flag Claims Units Chgs Paid
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R 9 12.750000 471.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 172 191.250000 8244.7500 0.0000
P 275 322.250000 15806.0000 15806.0000
D 2 3.500000 129.5000 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 458 529.750000 24652.0000 15806.0000