CMS/EIP Fiscal Report Center: 05
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 15 6.250000 231.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 31 136.250000 5041.2500 37.0000
Subtotal (Total Children Is Unduplicated) 31 142.500000 5272.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 13 23.000000 1598.2500 69.4891
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
TRAV-TRAVS-Travel by mile 2 20.000000 8.8900 0.4445
Subtotal (Total Children Is Unduplicated) 2 21.000000 18.8900 0.8995
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Total 186.500000 6889.6400 36.9418
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Number of Children (Unduplicated) With at Least One Service 31
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Center 05
Flag Claims Units Chgs Paid
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R 2 2.500000 187.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 83 81.500000 3072.5000 2397.2500
P 15 40.000000 1317.1400 1317.1400
D 1 0.500000 18.5000 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
80 62.000000 2294.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 181 186.500000 6889.6400 3714.3900