CMS/EIP Fiscal Report Center: 05
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 19 66.500000 2460.5000 37.0000
Subtotal (Total Children Is Unduplicated) 19 66.500000 2460.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 2 3.500000 262.5000 75.0000
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Total 70.000000 2723.0000 38.9000
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Number of Children (Unduplicated) With at Least One Service 19
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Center 05
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 85 69.250000 2695.2500 1803.7500
P 0 0.000000 0.0000 0.0000
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
1 0.750000 27.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 86 70.000000 2723.0000 1803.7500