CMS/EIP Fiscal Report Center: 53
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 77 152.250000 5633.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 89 170.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 102 468.000000 17316.0000 37.0000
Subtotal (Total Children Is Unduplicated) 103 790.250000 22949.2500 29.0405
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 450.0000 69.2308
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 18.500000 1387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.000000 825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 14.500000 1087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 53 84.000000 4662.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 64.500000 4837.5000 75.0000
Subtotal (Total Children Is Unduplicated) 80 219.000000 14613.0000 66.7260
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.750000 87.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.750000 37.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.500000 25.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 74 76.250000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 81 148.000000 1480.0000 10.0000
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 23 442.000000 196.6500 0.4449
Subtotal (Total Children Is Unduplicated) 81 670.250000 1898.0900 2.8319
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Total 1679.500000 39460.3400 23.4953
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Number of Children (Unduplicated) With at Least One Service 104
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Center 53
Flag Claims Units Chgs Paid
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R 4 3.500000 129.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 205 229.250000 10325.0000 150.0000
P 158 195.000000 8980.7500 8980.7500
D 0 0.000000 0.0000 0.0000
S 1 0.500000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 36 366.500000 623.5100 623.5100
861 871.500000 18836.3300 0.0000
Other 13 13.250000 565.2500 0.0000
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Total 1278 1679.500000 39460.3400 9754.2600