CMS/EIP Fiscal Report Center: 04
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 59 42.000000 1554.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 94 560.250000 20729.2500 37.0000
Subtotal (Total Children Is Unduplicated) 95 602.250000 22283.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 23.000000 1725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 27.500000 2062.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 82.000000 4551.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 30.000000 2442.7400 81.4247
Subtotal (Total Children Is Unduplicated) 79 165.500000 10986.7400 66.3851
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Total 767.750000 33269.9900 43.3344
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Number of Children (Unduplicated) With at Least One Service 95
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Center 04
Flag Claims Units Chgs Paid
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R 18 39.250000 1452.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 68 112.750000 4962.7500 0.0000
P 210 353.000000 15024.7400 14913.7400
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
267 262.750000 11830.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 563 767.750000 33269.9900 14913.7400