CMS/EIP Fiscal Report Center: 06
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 32 104.750000 3875.7500 37.0000
Subtotal (Total Children Is Unduplicated) 32 104.750000 3875.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 26.000000 1950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 10.500000 787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 25.500000 1415.2500 55.5000
Subtotal (Total Children Is Unduplicated) 26 69.000000 4677.7500 67.7935
-----------------------------------------------------------------------------------------------------------------------
Total 173.750000 8553.5000 49.2288
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 32
-----------------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
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
175 173.750000 8553.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 175 173.750000 8553.5000 0.0000