CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 3 8.500000 314.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 8.500000 314.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.000000 525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 20.500000 1137.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.000000 675.0000 75.0000
Subtotal (Total Children Is Unduplicated) 18 44.000000 2871.0000 65.2500
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 1 1.000000 71.4400 71.4400
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Total 53.500000 3256.9400 60.8774
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Number of Children (Unduplicated) With at Least One Service 20
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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 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
40 53.500000 3256.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 40 53.500000 3256.9400 0.0000