CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 711 1918.500000 70984.5000 37.0000
Subtotal (Total Children Is Unduplicated) 711 1918.500000 70984.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 28.500000 2137.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 26.000000 1950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 6.000000 450.0000 75.0000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 46 76.000000 5466.8500 71.9322
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 13.000000 650.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 2 11.000000 785.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 5 28.000000 1721.6000 61.4857
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Total 2022.500000 78172.9500 38.6516
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Number of Children (Unduplicated) With at Least One Service 712
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Center 05
Flag Claims Units Chgs Paid
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R 21 14.750000 685.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3081 2004.750000 77350.2000 52811.3700
P 1 2.000000 100.0000 100.0000
D 1 1.000000 37.0000 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 3104 2022.500000 78172.9500 52911.3700