CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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 667 1976.500000 73130.5000 37.0000
Subtotal (Total Children Is Unduplicated) 667 1976.500000 73130.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC 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
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 22 28.500000 2137.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.000000 300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 29 41.000000 3075.0000 75.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
PHY-97110GT-PT SESSION BY LICENSED PT 5 32.750000 2339.6600 71.4400
Subtotal (Total Children Is Unduplicated) 6 35.750000 2489.6600 69.6408
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Total 2053.250000 78695.1600 38.3271
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Number of Children (Unduplicated) With at Least One Service 667
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Center 05
Flag Claims Units Chgs Paid
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R 5 3.750000 233.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2823 2049.500000 78461.4100 13449.5050
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 2828 2053.250000 78695.1600 13449.5050