CMS/EIP Fiscal Report Center: 05
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 34 14.750000 545.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 65 316.250000 11701.2500 37.0000
Subtotal (Total Children Is Unduplicated) 65 331.000000 12247.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 12.500000 937.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 11.000000 825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 19 21.000000 1575.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 16.500000 915.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 11.500000 638.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
Subtotal (Total Children Is Unduplicated) 35 79.000000 5379.0000 68.0886
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 11 17.000000 170.0000 10.0000
TRAV-TRAVS-Travel by mile 4 41.000000 18.2300 0.4446
Subtotal (Total Children Is Unduplicated) 12 58.000000 188.2300 3.2453
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Total 468.000000 17814.2300 38.0646
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Number of Children (Unduplicated) With at Least One Service 65
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Center 05
Flag Claims Units Chgs Paid
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R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 136 133.500000 5167.5000 1110.0000
P 75 129.000000 4967.2300 4967.2300
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
235 204.500000 7604.5000 75.0000
Other 0 0.000000 0.0000 0.0000
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Total 447 468.000000 17814.2300 6152.2300