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
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 25 17.250000 638.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 35 164.500000 6086.5000 37.0000
Subtotal (Total Children Is Unduplicated) 52 182.750000 6724.7500 36.7975
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 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 13 21.000000 1575.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 12.000000 900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 16 27.500000 1526.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
Subtotal (Total Children Is Unduplicated) 28 81.500000 5547.0000 68.0614
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Total 264.250000 12271.7500 46.4399
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Number of Children (Unduplicated) With at Least One Service 58
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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 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
239 264.250000 12271.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 239 264.250000 12271.7500 0.0000