CMS/EIP Fiscal Report Center: 03
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 11 59.250000 2192.2500 37.0000
Subtotal (Total Children Is Unduplicated) 11 59.250000 2192.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
Subtotal (Total Children Is Unduplicated) 3 10.000000 652.5000 65.2500
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 7.500000 375.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 7.500000 375.0000 50.0000
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Total 76.750000 3219.7500 41.9511
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Number of Children (Unduplicated) With at Least One Service 11
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Center 03
Flag Claims Units Chgs Paid
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R 7 9.750000 473.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 66 62.500000 2521.0000 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
5 4.500000 225.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 78 76.750000 3219.7500 0.0000