CMS/EIP Fiscal Report Center: 57
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 975 3824.250000 141497.2500 37.0000
Subtotal (Total Children Is Unduplicated) 975 3824.250000 141497.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 11.500000 862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 18 21.000000 1575.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 16.000000 888.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 133 142.500000 10668.0000 74.8632
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 49 53.500000 4012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 201 238.500000 13236.7500 55.5000
Subtotal (Total Children Is Unduplicated) 214 483.000000 31242.7500 64.6848
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 3.000000 150.0000 50.0000
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Total 4310.250000 172890.0000 40.1114
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Number of Children (Unduplicated) With at Least One Service 975
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Center 57
Flag Claims Units Chgs Paid
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R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 362 430.000000 16690.7500 55.0000
P 3342 3867.250000 155281.2500 151937.2700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 11.500000 862.5000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 1 0.500000 18.5000 18.5000
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Total 3715 4310.250000 172890.0000 152010.7700