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
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 45 244.250000 9037.2500 37.0000
Subtotal (Total Children Is Unduplicated) 45 244.250000 9037.2500 37.0000
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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 16 28.500000 2137.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 27.000000 2025.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 6.500000 487.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 52.000100 2886.0055 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.500000 1687.5000 75.0000
Subtotal (Total Children Is Unduplicated) 40 138.500100 9334.5055 67.3971
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Total 382.750100 18371.7555 47.9993
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Number of Children (Unduplicated) With at Least One Service 47
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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
5 9.500000 605.2500 0.0000
Other 1 1.000000 55.5000 0.0000
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Total 356 382.750100 18371.7555 6141.7500