CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 639 1525.250000 56434.2500 37.0000
Subtotal (Total Children Is Unduplicated) 639 1525.250000 56434.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 47 69.500000 5212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 16.000000 1200.0000 75.0000
Subtotal (Total Children Is Unduplicated) 67 94.000000 7020.7500 74.6888
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 14.500000 725.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 1 2.750000 196.4600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 6.000000 342.9600 57.1600
Subtotal (Total Children Is Unduplicated) 5 23.250000 1264.4200 54.3837
-----------------------------------------------------------------------------------------------------------------------
Total 1642.500000 64719.4200 39.4030
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 649
-----------------------------------------------------------------------------------------------------------------------
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2473 1642.000000 64700.9200 39715.5000
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
2 0.500000 18.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2475 1642.500000 64719.4200 39715.5000