CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Payclass Filters:OTHER
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 40 71.750000 2654.7500 37.0000
Subtotal (Total Children Is Unduplicated) 40 71.750000 2654.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 5.500000 412.5000 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 4 5.500000 305.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 20 27.500000 2062.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 11.000000 825.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 27 38.000000 2109.0000 55.5000
Subtotal (Total Children Is Unduplicated) 32 89.500000 5864.2500 65.5223
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Total 161.250000 8519.0000 52.8310
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Number of Children (Unduplicated) With at Least One Service 41
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Center 09
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 1 2.000000 150.0000 150.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 93 131.000000 7323.7500 0.0000
T 0 0.000000 0.0000 0.0000
17 28.250000 1045.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 111 161.250000 8519.0000 150.0000