CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 Page: 1
List order: No List
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 48 77.250000 2858.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 62 268.750000 9943.7500 37.0000
Subtotal (Total Children Is Unduplicated) 62 346.000000 12802.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 6 10.500000 525.0000 50.0000
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 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 23.000000 1725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 27.500000 2062.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 13.500000 1012.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 34 65.000000 3607.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 29.000000 2175.0000 75.0000
Subtotal (Total Children Is Unduplicated) 47 191.500000 12679.5000 66.2115
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EI Services,Class #03
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 1 1.000000 71.4400 71.4400
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Total 538.500000 25552.9400 47.4521
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Number of Children (Unduplicated) With at Least One Service 62
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Center 53
Flag Claims Units Chgs Paid
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R 7 9.500000 351.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 128 145.000000 7653.5000 0.0000
P 85 92.750000 4263.2500 4263.2500
D 44 40.000000 1480.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.500000 83.2500 83.2500
298 249.500000 11712.1900 0.0000
Other 1 0.250000 9.2500 9.2500
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Total 564 538.500000 25552.9400 4355.7500