CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 09/30/2020 Date of Report:10/15/2020 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 50 119.500000 4412.2500 36.9226
TCM-T1017TL-TARGETED CASE MANAGEMENT 22 90.250000 3339.2500 37.0000
Subtotal (Total Children Is Unduplicated) 53 209.750000 7751.5000 36.9559
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 1 3.000000 195.7500 65.2500
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Total 212.750000 7947.2500 37.3549
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Number of Children (Unduplicated) With at Least One Service 53
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Center 53
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 0 0.000000 0.0000 0.0000
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
328 212.750000 7947.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 328 212.750000 7947.2500 0.0000