CMS/EIP Fiscal Report Center: 04
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 8 4.500000 166.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 39.000000 1443.0000 37.0000
Subtotal (Total Children Is Unduplicated) 10 43.500000 1609.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 6.000000 333.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 6 11.500000 726.0000 63.1304
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Total 55.000000 2335.5000 42.4636
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Number of Children (Unduplicated) With at Least One Service 10
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Center 04
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
42 55.000000 2335.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 42 55.000000 2335.5000 0.0000