CMS/EIP Fiscal Report Center: 03
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 25 17.250000 638.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 68 303.500000 11229.5000 37.0000
Subtotal (Total Children Is Unduplicated) 68 321.750000 11867.7500 36.8850
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 34 53.000000 3975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 32.500000 2437.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 17 28.500000 2137.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 20 34.000000 1887.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 33.500000 2512.5000 75.0000
Subtotal (Total Children Is Unduplicated) 60 187.500000 13370.2500 71.3080
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Total 509.250000 25238.0000 49.5592
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Number of Children (Unduplicated) With at Least One Service 70
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Center 03
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 135 180.000000 8091.2500 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
281 329.250000 17146.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 416 509.250000 25238.0000 0.0000