CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 39 16.500000 610.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 45 41.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 36 139.250000 5152.2500 37.0000
Subtotal (Total Children Is Unduplicated) 60 197.500000 5762.7500 29.1785
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 21.000000 1575.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 19.500000 1082.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 11.500000 862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 26 68.000000 4719.7500 69.4081
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EI Services,Class #03
INTR-T1013-INTERPRETER 2 3.000000 150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 20 32.000000 320.0000 10.0000
TRAV-TRAVS-Travel by mile 29 1075.000000 478.3100 0.4449
Subtotal (Total Children Is Unduplicated) 31 1110.000000 948.3100 0.8543
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Total 1375.500000 11430.8100 8.3103
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Number of Children (Unduplicated) With at Least One Service 63
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Center 05
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 111 1114.000000 5173.7300 5173.7300
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
290 261.500000 6257.0800 494.3300
Other 0 0.000000 0.0000 0.0000
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Total 401 1375.500000 11430.8100 5668.0600