CMS/EIP Fiscal Report Center: 57
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 35 16.250000 601.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 21.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 101 595.250000 22024.2500 37.0000
Subtotal (Total Children Is Unduplicated) 101 632.750000 22625.5000 35.7574
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 57 59.000000 4425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 32.000000 2400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 83 93.000000 5161.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 89 196.000000 12812.7500 65.3712
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.000000 350.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 11.000000 110.0000 10.0000
TRAV-TRAVS-Travel by mile 1 147.000000 65.4100 0.4450
Subtotal (Total Children Is Unduplicated) 4 165.000000 525.4100 3.1843
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Total 993.750000 35963.6600 36.1898
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Number of Children (Unduplicated) With at Least One Service 101
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Center 57
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 23 28.750000 1282.0000 18.5000
P 256 386.750000 16718.7500 16481.6000
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 12 169.000000 886.4100 886.4100
311 409.250000 17076.5000 200.0000
Other 0 0.000000 0.0000 0.0000
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Total 602 993.750000 35963.6600 17586.5100