CMS/EIP Fiscal Report Center: 55
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 140 157.750000 5836.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 20 17.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 143 544.000000 20128.0000 37.0000
Subtotal (Total Children Is Unduplicated) 148 718.750000 25964.7500 36.1249
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 5 16.000000 800.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 3 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 81 160.666667 12050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 76 160.000000 12000.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 52.000000 3900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 70.000000 3885.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 13.333333 1000.0000 75.0000
Subtotal (Total Children Is Unduplicated) 127 494.000000 35068.0000 70.9879
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 2.000000 20.0000 10.0000
Subtotal (Total Children Is Unduplicated) 1 4.000000 120.0000 30.0000
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Total 1216.750000 61152.7500 50.2591
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Number of Children (Unduplicated) With at Least One Service 149
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Center 55
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 94 132.000000 6100.0000 0.0000
P 325 414.116667 19287.2500 19248.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 10.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
596 660.633333 35015.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1020 1216.750000 61152.7500 19248.0000