CMS/EIP Fiscal Report Center: 57
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 63 39.250000 1452.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 69 455.750000 16862.7500 37.0000
Subtotal (Total Children Is Unduplicated) 105 495.000000 18315.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 3.000000 166.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 5.500000 305.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
Subtotal (Total Children Is Unduplicated) 11 26.000000 1784.2500 68.6250
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Total 521.000000 20099.2500 38.5782
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Number of Children (Unduplicated) With at Least One Service 105
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Center 57
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 0 0.000000 0.0000 0.0000
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 0 0.000000 0.0000 0.0000
397 521.000000 20099.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 397 521.000000 20099.2500 0.0000