CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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 762 1801.500000 66646.2500 36.9949
Subtotal (Total Children Is Unduplicated) 762 1801.500000 66646.2500 36.9949
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 24.500000 1837.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 65 116.000000 8700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.500000 787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 29.500000 2212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 75.500000 4190.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 23.500000 1762.5000 75.0000
SCREEN-T1023-SCREENING 20 21.000000 1050.0000 50.0000
Subtotal (Total Children Is Unduplicated) 107 328.500000 22396.5000 68.1781
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 27 78.000000 3900.0000 50.0000
Subtotal (Total Children Is Unduplicated) 27 78.000000 3900.0000 50.0000
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Total 2208.000000 92942.7500 42.0936
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Number of Children (Unduplicated) With at Least One Service 774
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Center 03
Flag Claims Units Chgs Paid
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R 76 50.750000 1877.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3194 2153.250000 90841.0000 0.0000
P 2 0.750000 27.7500 27.7500
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 3.250000 196.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3274 2208.000000 92942.7500 27.7500