CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 48 29.750000 1100.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 16 18.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 112 342.750000 12681.7500 37.0000
Subtotal (Total Children Is Unduplicated) 113 390.500000 13782.5000 35.2945
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
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 49 81.500000 6112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 18.500000 1387.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 62.000000 3441.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 18.500000 1387.5000 75.0000
SCREEN-T1023-SCREENING 4 9.000000 450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 71 231.500000 15792.0000 68.2160
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Total 622.000000 29574.5000 47.5474
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Number of Children (Unduplicated) With at Least One Service 113
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Center 03
Flag Claims Units Chgs Paid
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R 2 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 267 299.500000 14160.0000 0.0000
P 0 0.000000 0.0000 0.0000
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 0 0.000000 0.0000 0.0000
332 322.000000 15396.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 601 622.000000 29574.5000 0.0000