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: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 9 28.750000 1063.7500 37.0000
Subtotal (Total Children Is Unduplicated) 9 28.750000 1063.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 7 28.500000 1824.2500 64.0088
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Total 57.250000 2888.0000 50.4454
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Number of Children (Unduplicated) With at Least One Service 9
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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 65 57.250000 2888.0000 0.0000
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Total 65 57.250000 2888.0000 0.0000