CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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 24 100.750000 3727.7500 37.0000
Subtotal (Total Children Is Unduplicated) 24 100.750000 3727.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 33.000000 2475.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 20 38.000000 2109.0000 55.5000
Subtotal (Total Children Is Unduplicated) 21 101.000000 6795.0000 67.2772
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Total 201.750000 10522.7500 52.1574
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Number of Children (Unduplicated) With at Least One Service 24
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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 20 28.500000 1460.7500 0.0000
P 81 133.500000 6552.2500 6552.2800
D 0 0.000000 0.0000 0.0000
S 8 8.750000 379.7500 33.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16 31.000000 2130.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 125 201.750000 10522.7500 6586.0300