CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 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 60 368.250000 13625.2500 37.0000
Subtotal (Total Children Is Unduplicated) 60 368.250000 13625.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.000000 600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 29 41.500000 2303.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 84.500000 6337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 51 145.000000 10026.7500 69.1500
-----------------------------------------------------------------------------------------------------------------------
Total 513.250000 23652.0000 46.0828
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 60
-----------------------------------------------------------------------------------------------------------------------
Center 01
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 169 156.250000 6744.7500 0.0000
H 337 326.500000 14727.0000 14727.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 20 30.500000 2180.2500 0.0000
---------------------------------------------------------
Total 526 513.250000 23652.0000 14727.0000