CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 779 2027.000000 74999.0000 37.0000
Subtotal (Total Children Is Unduplicated) 779 2027.000000 74999.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.500000 787.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 81 141.500000 10612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 41 71.000000 5325.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 25.500000 1912.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 54 91.500000 5078.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 37.500000 2812.5000 75.0000
SCREEN-T1023-SCREENING 31 37.000000 1850.0000 50.0000
Subtotal (Total Children Is Unduplicated) 139 427.000000 29169.5000 68.3126
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 15 23.750000 1187.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 7.000000 485.8400 69.4057
Subtotal (Total Children Is Unduplicated) 16 30.750000 1673.3400 54.4176
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Total 2484.750000 105841.8400 42.5966
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Number of Children (Unduplicated) With at Least One Service 792
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Center 03
Flag Claims Units Chgs Paid
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R 43 32.000000 1221.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3212 2452.750000 104620.8400 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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3255 2484.750000 105841.8400 0.0000