CMS/EIP Fiscal Report Center: 57
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 28 14.250000 527.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 20.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 44 228.750000 8463.7500 37.0000
Subtotal (Total Children Is Unduplicated) 70 263.500000 8991.0000 34.1214
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 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 7 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 10.000000 555.0000 55.5000
Subtotal (Total Children Is Unduplicated) 11 21.500000 1378.5000 64.1163
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 8.000000 80.0000 10.0000
Subtotal (Total Children Is Unduplicated) 4 8.000000 80.0000 10.0000
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Total 293.000000 10449.5000 35.6638
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Number of Children (Unduplicated) With at Least One Service 71
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Center 57
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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 8 8.000000 80.0000 80.0000
216 285.000000 10369.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 224 293.000000 10449.5000 80.0000