CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 798 2533.000000 93675.7500 36.9821
Subtotal (Total Children Is Unduplicated) 798 2533.000000 93675.7500 36.9821
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 101 202.000000 15150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 15.303467 1147.7600 75.0000
Subtotal (Total Children Is Unduplicated) 117 233.303467 17380.7600 74.4985
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 45 311.250000 15562.5000 50.0000
Subtotal (Total Children Is Unduplicated) 45 311.250000 15562.5000 50.0000
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Total 3077.553467 126619.0100 41.1427
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Number of Children (Unduplicated) With at Least One Service 804
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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 930 729.250000 30554.5000 0.0000
P 2782 2345.500000 95911.2500 95681.0000
D 0 0.000000 0.0000 0.0000
S 1 1.303467 97.7600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 1.500000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3715 3077.553467 126619.0100 95681.0000