CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 18 80.500000 2978.5000 37.0000
Subtotal (Total Children Is Unduplicated) 18 80.500000 2978.5000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 23.500000 1762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 28.000000 1554.0000 55.5000
Subtotal (Total Children Is Unduplicated) 16 85.000000 5751.0000 67.6588
-----------------------------------------------------------------------------------------------------------------------
Total 165.500000 8729.5000 52.7462
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 18
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9 16.500000 1066.5000 150.0000
P 68 101.500000 5005.5000 5005.5000
D 0 0.000000 0.0000 0.0000
S 14 15.500000 647.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16 32.000000 2010.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 107 165.500000 8729.5000 5155.5000