CMS/EIP Fiscal Report Center: 53
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 49 76.750000 2821.2500 36.7590
TCM-T1017TL-TARGETED CASE MANAGEMENT 59 329.000000 12154.5000 36.9438
Subtotal (Total Children Is Unduplicated) 59 405.750000 14975.7500 36.9088
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 38.500000 2887.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 23 40.000000 3000.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 37 68.500000 3801.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 27.500000 2062.5000 75.0000
Subtotal (Total Children Is Unduplicated) 54 187.000000 12650.2500 67.6484
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 3.000000 150.0000 50.0000
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Total 595.750000 27776.0000 46.6236
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Number of Children (Unduplicated) With at Least One Service 63
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Center 53
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 217 227.500000 10722.0000 0.0000
P 121 129.250100 6141.7555 6141.7500
D 12 15.500000 847.2500 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
278 222.499900 10009.4945 0.0000
Other 1 1.000000 55.5000 0.0000
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Total 629 595.750000 27776.0000 6141.7500