CMS/EIP Fiscal Report Center: 52
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 9 3.000000 111.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 45 218.000000 8066.0000 37.0000
Subtotal (Total Children Is Unduplicated) 45 221.250000 8177.0000 36.9582
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 40 78.500000 5717.5000 72.8344
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 30.000000 2250.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 31.500000 2202.5000 69.9206
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 36 69.000000 3829.5000 55.5000
Subtotal (Total Children Is Unduplicated) 42 222.000000 14789.2500 66.6182
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.000000 0.0000 0.0000
TRAV-TRAVS-Travel by mile 18 335.000000 149.0300 0.4449
Subtotal (Total Children Is Unduplicated) 18 337.000000 149.0300 0.4422
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Total 780.250000 23115.2800 29.6255
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Number of Children (Unduplicated) With at Least One Service 45
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Center 52
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 20 28.500000 1460.7500 0.0000
P 86 143.500000 7119.2500 7010.2000
D 7 13.000000 721.5000 0.0000
S 10 11.250000 472.2500 33.7500
H 12 24.000000 1683.0000 0.0000
T 47 375.000000 2855.7800 2655.7800
124 185.000000 8802.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 306 780.250000 23115.2800 9699.7300