CMS/EIP Fiscal Report Center: 09
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 83 214.250000 7927.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 37 124.500000 4560.2500 36.6285
Subtotal (Total Children Is Unduplicated) 87 338.750000 12487.5000 36.8635
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 17.500000 1312.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 13 26.000000 1950.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
Subtotal (Total Children Is Unduplicated) 27 72.000000 5136.7500 71.3438
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EI Services,Class #03
INTR-T1013-INTERPRETER 1 2.500000 125.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 2.500000 125.0000 50.0000
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Total 413.250000 17749.2500 42.9504
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Number of Children (Unduplicated) With at Least One Service 87
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Center 09
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 163 241.500000 10514.7500 10514.7500
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 119 167.750000 6934.5000 6934.5000
0 0.000000 0.0000 0.0000
Other 2 4.000000 300.0000 0.0000
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Total 284 413.250000 17749.2500 17449.2500