CMS/EIP Fiscal Report Center: 55
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 84 390.500000 14402.2500 36.8816
Subtotal (Total Children Is Unduplicated) 84 390.500000 14402.2500 36.8816
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 69 139.000000 10425.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 28 55.000000 4125.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 30 60.000000 3330.0000 55.5000
Subtotal (Total Children Is Unduplicated) 76 292.000000 20613.0000 70.5925
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 50.0000 50.0000
-----------------------------------------------------------------------------------------------------------------------
Total 683.500000 35065.2500 51.3025
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 84
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 361 464.500000 22516.2500 0.0000
P 132 123.000000 5725.0000 5725.0000
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
49 96.000000 6824.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 542 683.500000 35065.2500 5725.0000