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
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 119 463.250000 17140.2500 37.0000
Subtotal (Total Children Is Unduplicated) 119 463.250000 17140.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 1 2.000000 150.0000 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 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 83 164.836800 12362.7600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 28 59.622000 4471.6500 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 16 32.000000 2400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 25 52.000000 2886.0000 55.5000
Subtotal (Total Children Is Unduplicated) 97 348.458800 24769.4100 71.0828
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Total 811.708800 41909.6600 51.6314
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Number of Children (Unduplicated) With at Least One Service 119
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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 69 85.000000 3677.0000 21939.2500
D 0 0.000000 0.0000 0.0000
S 1 0.836800 62.7600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
92 181.872000 12265.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 592 811.708800 41909.6600 21939.2500