CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 111 131.250000 4856.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 18 15.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 28 103.250000 3820.2500 37.0000
Subtotal (Total Children Is Unduplicated) 113 250.000000 8676.5000 34.7060
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 3 5.000000 250.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 9.860266 739.5200 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.170266 687.7700 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.657600 274.3200 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
Subtotal (Total Children Is Unduplicated) 16 41.688132 2728.6100 65.4529
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Total 291.688132 11405.1100 39.1004
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Number of Children (Unduplicated) With at Least One Service 113
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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 0 0.000000 0.0000 0.0000
P 13 23.342799 1452.7100 1452.7100
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
337 268.345333 9952.4000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 350 291.688132 11405.1100 1452.7100