CMS/EIP Fiscal Report Center: 06
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 77 54.500000 2016.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 40 196.000000 7252.0000 37.0000
Subtotal (Total Children Is Unduplicated) 85 253.000000 9268.5000 36.6344
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 5 13.000000 906.7500 69.7500
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 3.000000 30.0000 10.0000
Subtotal (Total Children Is Unduplicated) 3 3.000000 30.0000 10.0000
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Total 269.000000 10205.2500 37.9377
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Number of Children (Unduplicated) With at Least One Service 85
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Center 06
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 1 1.000000 10.0000 10.0000
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
394 268.000000 10195.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 395 269.000000 10205.2500 10.0000