CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 ending 06/30/2020 Date of Report:07/20/2020 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 224 452.500000 16742.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 207 304.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 104 503.000000 18611.0000 37.0000
Subtotal (Total Children Is Unduplicated) 264 1259.500000 35353.5000 28.0695
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 24.000000 1332.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 6.500000 360.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 11.500000 862.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
Subtotal (Total Children Is Unduplicated) 32 77.500000 5139.7500 66.3194
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.250000 162.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 2.250000 112.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.500000 125.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 1.500000 75.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 179 212.500000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 202 420.000000 4200.0000 10.0000
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 69 1893.000000 842.1700 0.4449
Subtotal (Total Children Is Unduplicated) 202 2536.000000 5588.6100 2.2037
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Total 3873.000000 46081.8600 11.8982
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Number of Children (Unduplicated) With at Least One Service 269
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Center 53
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 0 0.000000 0.0000 0.0000
D 23 26.000000 1189.0000 0.0000
S 1 0.500000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 213 2030.000000 3556.4200 3556.4200
2347 1816.500000 41336.4400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2584 3873.000000 46081.8600 3556.4200