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
Payclass Filters:GR
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 17 78.750000 2913.7500 37.0000
Subtotal (Total Children Is Unduplicated) 53 156.000000 5772.0000 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 5 8.500000 425.0000 50.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 10.000000 555.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 15 38.500000 2405.0000 62.4675
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Total 194.500000 8177.0000 42.0411
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Number of Children (Unduplicated) With at Least One Service 53
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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 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 1 1.500000 83.2500 83.2500
265 193.000000 8093.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 266 194.500000 8177.0000 83.2500