CMS/EIP Fiscal Report Center: 55
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 835 2922.250000 108123.2500 37.0000
Subtotal (Total Children Is Unduplicated) 835 2922.250000 108123.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 101 200.666666 15050.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 20.000000 1500.0000 75.0000
Subtotal (Total Children Is Unduplicated) 115 228.666666 17150.0000 75.0000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 49 342.750000 17137.5000 50.0000
Subtotal (Total Children Is Unduplicated) 49 342.750000 17137.5000 50.0000
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Total 3493.666666 142410.7500 40.7625
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Number of Children (Unduplicated) With at Least One Service 842
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Center 55
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 1575 1314.750000 55126.5000 77.7500
P 2655 2156.750000 86265.2500 89783.6800
D 0 0.000000 0.0000 0.0000
S 2 2.666666 200.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.750000 27.7500 27.7500
29 18.750000 791.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4262 3493.666666 142410.7500 89889.1800