CMS/EIP Fiscal Report Center: 10
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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 67 60.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 162 633.000000 23421.0000 37.0000
Subtotal (Total Children Is Unduplicated) 162 693.750000 23421.0000 33.7600
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 86 154.000000 11550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 35.500000 2662.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 87 162.000000 8991.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 28.500000 2137.5000 75.0000
Subtotal (Total Children Is Unduplicated) 114 431.000000 29010.0000 67.3086
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Total 1124.750000 52431.0000 46.6157
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Number of Children (Unduplicated) With at Least One Service 163
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Center 10
Flag Claims Units Chgs Paid
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R 10 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 100 115.000000 5087.0000 0.0000
P 324 394.250000 19021.2500 19021.2500
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
519 608.000000 28045.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 953 1124.750000 52431.0000 19021.2500