CMS/EIP Fiscal Report Center: 51
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 17 63.250000 2303.2500 36.4150
Subtotal (Total Children Is Unduplicated) 17 63.250000 2303.2500 36.4150
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 12.000000 666.0000 55.5000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 14 23.000000 1441.0000 62.6522
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Total 86.250000 3744.2500 43.4116
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Number of Children (Unduplicated) With at Least One Service 19
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Center 51
Flag Claims Units Chgs Paid
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R 2 2.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 43 34.250000 1498.7500 0.0000
P 3 3.000000 166.5000 166.5000
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
64 47.000000 1968.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 112 86.250000 3744.2500 166.5000