CMS/EIP Fiscal Report Center: 55
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 148 193.500000 7159.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 3.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 158 611.250000 22616.2500 37.0000
Subtotal (Total Children Is Unduplicated) 164 807.750000 29775.7500 36.8626
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 113 226.000000 16950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 42 88.000000 6600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 40.000000 3000.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.000000 1110.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 58.000000 3219.0000 55.5000
Subtotal (Total Children Is Unduplicated) 133 478.000000 34101.0000 71.3410
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
TRAV-TRAVS-Travel by mile 1 28.000000 12.4600 0.4450
Subtotal (Total Children Is Unduplicated) 1 29.000000 22.4600 0.7745
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Total 1314.750000 63899.2100 48.6018
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Number of Children (Unduplicated) With at Least One Service 164
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Center 55
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 430 544.000000 25904.0000 0.0000
P 90 151.533333 6347.4600 24609.7100
D 0 0.000000 0.0000 0.0000
S 1 0.836800 62.7600 0.0000
H 12 24.000000 1800.0000 0.0000
T 0 0.000000 0.0000 0.0000
639 594.379867 29784.9900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1172 1314.750000 63899.2100 24609.7100