CMS/EIP Fiscal Report Center: 52
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 Page: 1
List order: No List
Payclass Filters:TPIN
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 1 2.500000 92.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 2.500000 92.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 28.000000 1570.0000 56.0714
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 18.000000 1050.0000 58.3333
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 11.500000 522.5000 45.4348
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 9 17.000000 943.5000 55.5000
Subtotal (Total Children Is Unduplicated) 15 100.500000 5919.0000 58.8955
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Total 103.000000 6011.5000 58.3641
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Number of Children (Unduplicated) With at Least One Service 15
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Center 52
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 7 14.000000 639.0600 633.0200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 8.000000 561.0000 0.0000
T 17 34.000000 1819.9400 1819.9400
25 47.000000 2991.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 53 103.000000 6011.5000 2452.9600