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
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 11 19.500000 721.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 24.500000 906.5000 37.0000
Subtotal (Total Children Is Unduplicated) 12 44.000000 1628.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 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 6 6.000000 333.0000 55.5000
Subtotal (Total Children Is Unduplicated) 7 13.000000 858.0000 66.0000
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Total 57.000000 2486.0000 43.6140
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Number of Children (Unduplicated) With at Least One Service 13
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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 0 0.000000 0.0000 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
59 52.000000 2111.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 64 57.000000 2486.0000 375.0000