CMS/EIP Fiscal Report Center: 07
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Payclass Filters:TPIN
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 3 10.750000 397.7500 37.0000
Subtotal (Total Children Is Unduplicated) 3 10.750000 397.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.300000 322.5000 75.0000
Subtotal (Total Children Is Unduplicated) 4 6.300000 472.5000 75.0000
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Total 17.050000 870.2500 51.0411
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Number of Children (Unduplicated) With at Least One Service 7
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Center 07
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 0 0.000000 0.0000 0.0000
P 2 2.800000 210.0000 210.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
11 12.250000 510.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14 17.050000 870.2500 210.0000