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
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 554 351.750000 13014.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 32 25.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 530 2500.000000 92490.7500 36.9963
Subtotal (Total Children Is Unduplicated) 896 2876.750000 105505.5000 36.6752
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 8 8.000000 400.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 7 10.000000 500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 14.000000 1050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.500000 712.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 15.500000 860.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.000000 525.0000 75.0000
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 42 89.500000 5731.5500 64.0397
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EI Services,Class #03
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 6.000000 300.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.500000 18.5000 37.0000
Subtotal (Total Children Is Unduplicated) 6 12.500000 661.3800 52.9104
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Total 2978.750000 111898.4300 37.5656
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Number of Children (Unduplicated) With at Least One Service 902
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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
3302 2978.750000 111898.4300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3302 2978.750000 111898.4300 0.0000