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
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 4 1.250000 46.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 11.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 33 132.750000 4911.7500 37.0000
Subtotal (Total Children Is Unduplicated) 45 145.500000 4958.0000 34.0756
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
Subtotal (Total Children Is Unduplicated) 4 15.500000 1045.5000 67.4516
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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 958.000000 6358.1000 6.6368
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Number of Children (Unduplicated) With at Least One Service 55
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 12 14.250000 527.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 64 812.500000 1400.1000 1345.1000
139 131.250000 4430.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 215 958.000000 6358.1000 1345.1000