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
Payclass Filters:GR
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 384 1127.750000 41726.7500 37.0000
Subtotal (Total Children Is Unduplicated) 603 1270.500000 47008.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.000000 75.0000 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 2 3.500000 262.5000 75.0000
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 8 10.000000 706.5500 70.6550
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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
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 18.000000 180.0000 10.0000
PHY-97110GT-PT SESSION BY LICENSED PT 3 30.000000 2143.2000 71.4400
Subtotal (Total Children Is Unduplicated) 8 54.750000 2610.7000 47.6840
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Total 1335.250000 50325.7500 37.6901
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Number of Children (Unduplicated) With at Least One Service 607
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Center 05
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 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
2053 1274.000000 47063.5000 55.0000
Other 0 0.000000 0.0000 0.0000
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Total 2088 1335.250000 50325.7500 3317.2500