CMS/EIP Fiscal Report Center: 05
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 678 1501.250000 55546.2500 37.0000
Subtotal (Total Children Is Unduplicated) 678 1501.250000 55546.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 40 58.000000 4350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 43 65.500000 4834.5000 73.8092
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 18.500000 925.0000 50.0000
Subtotal (Total Children Is Unduplicated) 8 24.500000 1075.0000 43.8776
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Total 1591.250000 61455.7500 38.6211
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Number of Children (Unduplicated) With at Least One Service 679
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Center 05
Flag Claims Units Chgs Paid
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R 15 11.250000 501.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2395 1571.000000 60621.7500 43378.9900
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
13 9.000000 333.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2423 1591.250000 61455.7500 43378.9900