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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 672 1647.250000 60948.2500 37.0000
Subtotal (Total Children Is Unduplicated) 672 1647.250000 60948.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 51 75.000000 5625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 16.000000 1200.0000 75.0000
Subtotal (Total Children Is Unduplicated) 74 103.500000 7704.0000 74.4348
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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
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Total 1774.000000 69916.6700 39.4119
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Number of Children (Unduplicated) With at Least One Service 682
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Center 05
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 2610 1773.500000 69898.1700 42287.0000
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
2 0.500000 18.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2612 1774.000000 69916.6700 42287.0000