CMS/EIP Fiscal Report Center: 52
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 4 1.250000 46.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 11.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 69 262.750000 9684.7500 36.8592
Subtotal (Total Children Is Unduplicated) 69 275.500000 9731.0000 35.3212
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 85.500000 6167.5000 72.1345
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 43.000000 3160.6500 73.5035
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 22.000000 1650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 104.500000 5688.7500 54.4378
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 15.500000 1162.5000 75.0000
Subtotal (Total Children Is Unduplicated) 53 276.500000 18240.4000 65.9689
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EI Services,Class #03
TRAV-TRAVS-Travel by mile 33 797.000000 354.6000 0.4449
Subtotal (Total Children Is Unduplicated) 33 797.000000 354.6000 0.4449
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Total 1349.000000 28326.0000 20.9978
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Number of Children (Unduplicated) With at Least One Service 69
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Center 52
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 13 14.500000 612.5000 0.0000
P 110 173.500000 8638.5000 8437.8500
D 0 0.000000 0.0000 0.0000
S 22 24.500000 1058.5000 0.0000
H 19 38.000000 2850.0000 0.0000
T 86 855.500000 3954.8300 3759.8300
197 243.000000 11211.6700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 447 1349.000000 28326.0000 12197.6800