CMS/EIP Fiscal Report Center: 10
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 115 486.750000 18009.7500 37.0000
Subtotal (Total Children Is Unduplicated) 115 486.750000 18009.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 11.000000 825.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 61 113.000000 8475.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 29 48.000000 3600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 5.000000 375.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 13 23.500000 1762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 19.500000 1082.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 55 99.000000 5494.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 21.000000 1575.0000 75.0000
Subtotal (Total Children Is Unduplicated) 95 361.000000 24618.0000 68.1939
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Total 847.750000 42627.7500 50.2834
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Number of Children (Unduplicated) With at Least One Service 116
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Center 10
Flag Claims Units Chgs Paid
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R 27 23.750000 878.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 110 109.750000 4931.7500 0.0000
P 281 299.750000 13917.5000 13917.5200
D 1 2.250000 83.2500 0.0000
S 45 78.000000 5313.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
243 310.750000 15876.7500 0.0000
Other 14 23.500000 1626.0000 0.0000
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Total 721 847.750000 42627.7500 13917.5200