CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 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 8 4.500000 166.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 18 139.500000 5161.5000 37.0000
Subtotal (Total Children Is Unduplicated) 18 144.000000 5328.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.500000 138.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 6.000000 450.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.000000 666.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 4.500000 337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 9 28.000000 1817.2500 64.9018
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EI Services,Class #03
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
Subtotal (Total Children Is Unduplicated) 1 2.000000 114.4000 57.2000
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Total 174.000000 7259.6500 41.7221
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Number of Children (Unduplicated) With at Least One Service 18
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Center 04
Flag Claims Units Chgs Paid
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R 6 9.750000 360.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 55 84.500000 3126.5000 0.0000
P 4 6.250000 231.2500 231.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 114.4000 0.0000
T 0 0.000000 0.0000 0.0000
56 71.500000 3426.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 122 174.000000 7259.6500 231.2500