CMS/EIP Fiscal Report Center: 07
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 38 109.000000 4023.7500 36.9151
Subtotal (Total Children Is Unduplicated) 38 109.000000 4023.7500 36.9151
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 31.500000 1748.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 31.000000 2325.0000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 26 73.500000 4873.2500 66.3027
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Total 182.500000 8897.0000 48.7507
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Number of Children (Unduplicated) With at Least One Service 40
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Center 07
Flag Claims Units Chgs Paid
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R 8 5.000000 185.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 28.250000 1310.2500 0.0000
P 111 144.000000 7207.5000 7257.5000
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
6 5.250000 194.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 149 182.500000 8897.0000 7257.5000