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: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 14 100.500000 3718.5000 37.0000
Subtotal (Total Children Is Unduplicated) 14 100.500000 3718.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 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 3 4.000000 300.0000 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 15.000000 978.7500 65.2500
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EI Services,Class #03
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
Subtotal (Total Children Is Unduplicated) 1 2.000000 114.4000 57.2000
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Total 117.500000 4811.6500 40.9502
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Number of Children (Unduplicated) With at Least One Service 14
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Center 04
Flag Claims Units Chgs Paid
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R 6 9.750000 360.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 55 84.500000 3126.5000 0.0000
P 4 6.250000 231.2500 231.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 114.4000 0.0000
T 0 0.000000 0.0000 0.0000
13 15.000000 978.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 79 117.500000 4811.6500 231.2500