CMS/EIP Fiscal Report Center: 05
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 17 80.500000 2978.5000 37.0000
Subtotal (Total Children Is Unduplicated) 17 80.500000 2978.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
Subtotal (Total Children Is Unduplicated) 3 4.000000 300.0000 75.0000
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Total 84.500000 3278.5000 38.7988
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Number of Children (Unduplicated) With at Least One Service 17
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Center 05
Flag Claims Units Chgs Paid
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R 2 2.500000 187.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 83 81.500000 3072.5000 2397.2500
P 0 0.000000 0.0000 0.0000
D 1 0.500000 18.5000 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 0 0.000000 0.0000 0.0000
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Total 86 84.500000 3278.5000 2397.2500