CMS/EIP Fiscal Report Center: 57
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 30 178.500000 6604.5000 37.0000
Subtotal (Total Children Is Unduplicated) 30 178.500000 6604.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 6.500000 487.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 15.000000 1125.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 19 25.000000 1387.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.500000 337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 23 59.000000 3937.5000 66.7373
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 16.000000 800.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 16.000000 800.0000 50.0000
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Total 253.500000 11342.0000 44.7416
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Number of Children (Unduplicated) With at Least One Service 30
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Center 57
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 19 25.000000 1236.2500 0.0000
P 138 211.500000 9230.7500 9155.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 75.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 16.000000 800.0000 800.0000
Other 0 0.000000 0.0000 0.0000
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Total 160 253.500000 11342.0000 9955.7500