CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 ending 06/30/2019 Date of Report:07/21/2019 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 8.250000 305.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 8.250000 305.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 20.999999 1574.9999 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.500000 862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 11.500000 862.5001 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 75.000300 4162.5167 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 51.500000 3862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 61 173.500299 11550.0167 66.5706
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 10.000000 500.0000 50.0000
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Total 191.750299 12355.2667 64.4341
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Number of Children (Unduplicated) With at Least One Service 62
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Center 53
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 0 0.000000 0.0000 0.0000
P 5 5.529798 343.9165 365.6700
D 9 14.500000 965.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 8.500000 530.2500 530.2500
T 0 0.000000 0.0000 0.0000
61 87.220501 5474.8502 0.0000
Other 50 76.000000 5041.2500 0.0000
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Total 130 191.750299 12355.2667 895.9200