CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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 5.500000 203.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 116 456.750000 16899.7500 37.0000
Subtotal (Total Children Is Unduplicated) 116 462.250000 17103.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
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 2 3.000000 213.1600 71.0533
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 3.000000 225.0000 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 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 34 50.500000 3787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 20 30.000000 2250.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 41 60.500000 3357.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 63.500000 4762.5000 75.0000
Subtotal (Total Children Is Unduplicated) 84 244.000000 16932.9100 69.3972
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
INTR-T1013-INTERPRETER 14 19.750000 987.5000 50.0000
TRAV-TRAVS-Travel by mile 1 19.000000 8.4500 0.4447
Subtotal (Total Children Is Unduplicated) 15 38.750000 995.9500 25.7019
-----------------------------------------------------------------------------------------------------------------------
Total 745.000000 35032.1100 47.0230
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 119
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 16 23.750000 1470.7500 1470.7500
D 3 2.750000 163.1600 0.0000
S 187 171.500000 8446.0000 0.0000
H 236 211.250000 9634.2500 7817.5000
T 15 40.250000 1255.2000 1255.2000
304 245.000000 10938.0000 0.0000
Other 53 50.500000 3124.7500 0.0000
---------------------------------------------------------
Total 814 745.000000 35032.1100 10543.4500