CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 ending 06/30/2020 Date of Report:07/20/2020 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 179 109.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 266 392.750000 14513.2500 36.9529
Subtotal (Total Children Is Unduplicated) 266 502.000000 14513.2500 28.9109
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.000000 900.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.000000 675.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 21.000000 1165.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 120 173.500000 13012.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 45 59.000000 4387.5000 74.3644
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 62 103.000000 7725.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 32 40.500000 3037.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 180 272.500000 15123.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 72 91.000000 5022.7500 55.1951
Subtotal (Total Children Is Unduplicated) 274 800.500000 52416.0000 65.4791
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Total 1302.500000 66929.2500 51.3852
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Number of Children (Unduplicated) With at Least One Service 274
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Center 09
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 87 112.000000 5742.2500 5742.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 903 1173.000000 59874.5000 0.0000
T 0 0.000000 0.0000 0.0000
6 11.500000 862.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 996 1296.500000 66479.2500 5742.2500
Center 55
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 0 0.000000 0.0000 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
3 6.000000 450.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3 6.000000 450.0000 0.0000