CMS/EIP Fiscal Report Center: 55
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 133 174.000000 6438.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 28 29.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 143 618.000000 22829.0000 36.9401
Subtotal (Total Children Is Unduplicated) 151 821.250000 29267.0000 35.6371
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 5 18.000000 900.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 599.9999 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000532 450.0400 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 72 144.930534 10869.7900 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 65 129.499999 9712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 60.000000 3330.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 21.069467 1580.2100 75.0000
Subtotal (Total Children Is Unduplicated) 112 397.500532 28153.5399 70.8264
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 8.000000 80.0000 10.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 8.000000 571.5200 71.4400
Subtotal (Total Children Is Unduplicated) 1 16.000000 651.5200 40.7200
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Total 1234.750532 58072.0599 47.0314
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Number of Children (Unduplicated) With at Least One Service 151
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Center 55
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 176 195.250000 8212.2500 18.5000
P 296 364.969067 17277.6800 22232.4800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 12.500000 842.5000 0.0000
T 0 0.000000 0.0000 0.0000
663 662.031465 31739.6299 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1141 1234.750532 58072.0599 22250.9800