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
Agency Filter:EIP DEI DEIP
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 346 142.750000 5281.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1021 2977.250000 110158.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1023 3120.000000 115440.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 19 27.000000 2025.0000 75.0000
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 3 3.000000 225.0000 75.0000
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 30 42.500000 3144.0500 73.9776
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.250000 112.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 3 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 18.000000 180.0000 10.0000
PHY-97110GT-PT SESSION BY LICENSED PT 8 62.750000 4482.8600 71.4400
Subtotal (Total Children Is Unduplicated) 12 90.500000 5100.3600 56.3576
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Total 3253.000000 123684.4100 38.0216
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Number of Children (Unduplicated) With at Least One Service 1023
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Center 05
Flag Claims Units Chgs Paid
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R 3 1.250000 46.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2685 1914.750000 73247.6600 12339.5050
P 35 61.250000 3262.2500 3262.2500
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
2056 1275.750000 47128.2500 55.0000
Other 0 0.000000 0.0000 0.0000
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Total 4779 3253.000000 123684.4100 15656.7550