CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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 32 49.250000 1822.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 5 3.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 9 22.250000 823.2500 37.0000
Subtotal (Total Children Is Unduplicated) 32 74.500000 2645.5000 35.5101
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.000000 666.0000 55.5000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 9 27.000000 1702.0000 63.0370
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EI Services,Class #03
INTR-T1013-INTERPRETER 1 4.000000 200.0000 50.0000
TRAV-TRAVS-Travel by mile 7 288.000000 128.1600 0.4450
Subtotal (Total Children Is Unduplicated) 7 292.000000 328.1600 1.1238
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Total 393.500000 4675.6600 11.8822
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Number of Children (Unduplicated) With at Least One Service 34
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Center 02
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 10 294.000000 478.1600 478.1600
0 0.000000 0.0000 0.0000
Other 156 99.500000 4197.5000 0.0000
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Total 166 393.500000 4675.6600 478.1600