CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Payclass Filters:OTHER
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 69 35.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 75 112.500000 4116.2500 36.5889
Subtotal (Total Children Is Unduplicated) 75 148.250000 4116.2500 27.7656
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 48 69.000000 5175.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 39.000000 2925.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 108.000000 5994.0000 55.5000
Subtotal (Total Children Is Unduplicated) 76 226.000000 14775.7500 65.3794
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Total 374.250000 18892.0000 50.4796
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Number of Children (Unduplicated) With at Least One Service 77
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Center 09
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 96 123.500000 6357.2500 6357.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 197 250.500000 12525.5000 0.0000
T 0 0.000000 0.0000 0.0000
1 0.250000 9.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 294 374.250000 18892.0000 6357.2500