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
Payclass Filters:GR
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 47 203.750000 7501.7500 36.8184
Subtotal (Total Children Is Unduplicated) 137 407.000000 13939.7500 34.2500
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 5 16.000000 800.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.038134 77.8600 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.492666 111.9500 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 27.174001 2038.0500 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 22.015466 1651.1600 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.069467 380.2100 75.0000
Subtotal (Total Children Is Unduplicated) 30 82.789734 5614.2300 67.8131
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 8.000000 80.0000 10.0000
Subtotal (Total Children Is Unduplicated) 1 8.000000 80.0000 10.0000
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Total 497.789734 19633.9800 39.4423
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Number of Children (Unduplicated) With at Least One Service 138
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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 0 0.000000 0.0000 0.0000
P 29 45.969067 2510.6800 2510.6800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.500000 92.5000 0.0000
T 0 0.000000 0.0000 0.0000
540 449.320667 17030.8000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 570 497.789734 19633.9800 2510.6800