CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 59 42.250000 1563.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 90 545.250000 20174.2500 37.0000
Subtotal (Total Children Is Unduplicated) 90 587.500000 21737.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 1.000000 563.1000 563.1000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 23.500000 1762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 30.500000 2287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 82 87.500000 4856.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 42.000000 4758.5600 113.2990
Subtotal (Total Children Is Unduplicated) 89 191.000000 14637.4100 76.6357
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Total 778.500000 36374.9100 46.7244
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Number of Children (Unduplicated) With at Least One Service 90
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Center 04
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 72 130.000000 5384.7500 0.0000
P 171 304.750000 15195.6600 15199.1800
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
337 343.750000 15794.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 580 778.500000 36374.9100 15199.1800