CMS/EIP Fiscal Report Center: 52
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 18 9.750000 342.2500 35.1026
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 0.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 130.500000 4819.2500 36.9291
Subtotal (Total Children Is Unduplicated) 30 140.750000 5161.5000 36.6714
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 18 43.000000 2695.0000 62.6744
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 20.000000 1200.0000 60.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 15.000000 785.0000 52.3333
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 13 25.000000 1387.5000 55.5000
Subtotal (Total Children Is Unduplicated) 26 143.000000 8843.2500 61.8409
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 1.000000 0.0000 0.0000
TRAV-TRAVS-Travel by mile 8 263.000000 117.0000 0.4449
Subtotal (Total Children Is Unduplicated) 8 264.000000 117.0000 0.4432
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Total 547.750000 14121.7500 25.7814
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Number of Children (Unduplicated) With at Least One Service 30
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Center 52
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 40 57.000000 2716.0000 0.0000
P 14 22.250000 944.3100 938.2700
D 0 0.000000 0.0000 0.0000
S 3 3.500000 129.5000 0.0000
H 4 8.000000 561.0000 0.0000
T 31 301.000000 2197.9400 2157.9400
124 156.000000 7573.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 216 547.750000 14121.7500 3096.2100