CMS/EIP Fiscal Report Center: 51
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 Page: 1
List order: No List
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 11 19.500000 721.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 42.500000 1572.5000 37.0000
Subtotal (Total Children Is Unduplicated) 12 62.000000 2294.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 9.500000 712.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 15.500000 860.2500 55.5000
Subtotal (Total Children Is Unduplicated) 14 29.000000 1872.7500 64.5776
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Total 91.000000 4166.7500 45.7885
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Number of Children (Unduplicated) With at Least One Service 15
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Center 51
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 26 29.000000 1325.2500 0.0000
P 5 5.000000 375.0000 375.0000
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
64 57.000000 2466.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 95 91.000000 4166.7500 375.0000