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
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 9 3.000000 111.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 21 117.250000 4338.2500 37.0000
Subtotal (Total Children Is Unduplicated) 27 120.500000 4449.2500 36.9232
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 2 8.000000 522.0000 65.2500
-----------------------------------------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------------------------------------
Total 465.500000 5120.2800 10.9995
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 33
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2.000000 111.0000 59.4800
D 0 0.000000 0.0000 0.0000
S 2 2.500000 92.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 28 339.000000 449.0300 429.0300
90 122.000000 4467.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 121 465.500000 5120.2800 488.5100