CMS/EIP Fiscal Report Center: 05
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:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 345 144.250000 5337.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 386 361.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 443 1101.250000 40746.2500 37.0000
Subtotal (Total Children Is Unduplicated) 758 1606.500000 46083.5000 28.6857
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 28.500000 2137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.000000 277.5000 55.5000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 22 37.500000 2617.1000 69.7893
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 3.500000 175.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 9.000000 450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12 29.000000 290.0000 10.0000
PHY-97110-PT SESSION BY LICENSED PT 2 13.000000 928.7200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 14.000000 1000.1600 71.4400
TRAV-TRAVS-Travel by mile 12 598.000000 266.0500 0.4449
Subtotal (Total Children Is Unduplicated) 22 676.000000 3472.4300 5.1367
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Total 2320.000000 52173.0300 22.4884
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Number of Children (Unduplicated) With at Least One Service 764
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Center 05
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 1 0.250000 9.2500 0.0000
P 101 693.000000 6046.0800 6046.0800
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
2697 1626.750000 46117.7000 43.4500
Other 0 0.000000 0.0000 0.0000
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Total 2799 2320.000000 52173.0300 6089.5300