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
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 60 28.500000 1054.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 35 36.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 112 362.500000 13412.5000 37.0000
Subtotal (Total Children Is Unduplicated) 112 427.250000 14467.0000 33.8607
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 70.500000 5287.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 25.000000 1875.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 58.000000 3219.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 17.000000 1275.0000 75.0000
SCREEN-T1023-SCREENING 6 9.000000 450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 65 212.000000 14427.0000 68.0519
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Total 639.250000 28894.0000 45.1998
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Number of Children (Unduplicated) With at Least One Service 112
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Center 03
Flag Claims Units Chgs Paid
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R 7 6.250000 231.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 297 296.750000 13597.7500 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
383 336.250000 15065.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 687 639.250000 28894.0000 0.0000