CMS/EIP Fiscal Report Center: 02
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 19 30.000000 1110.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 27.750000 1026.7500 37.0000
Subtotal (Total Children Is Unduplicated) 19 57.750000 2136.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.000000 825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
Subtotal (Total Children Is Unduplicated) 8 26.000000 1725.7500 66.3750
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Total 83.750000 3862.5000 46.1194
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Number of Children (Unduplicated) With at Least One Service 20
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Center 02
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 0 0.000000 0.0000 0.0000
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
0 0.000000 0.0000 0.0000
Other 134 83.750000 3862.5000 0.0000
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Total 134 83.750000 3862.5000 0.0000