CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 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 62 89.000000 3293.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 80 439.000000 16196.7500 36.8946
Subtotal (Total Children Is Unduplicated) 81 528.000000 19489.7500 36.9124
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Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 7 10.500000 525.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 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 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 37 62.000000 4650.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 26 43.000000 3225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 19 28.500000 2137.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 53 94.500000 5272.5000 55.7937
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 23.500000 1762.5000 75.0000
Subtotal (Total Children Is Unduplicated) 71 283.500000 19038.7500 67.1561
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Total 811.500000 38528.5000 47.4781
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Number of Children (Unduplicated) With at Least One Service 81
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Center 53
Flag Claims Units Chgs Paid
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R 150 153.500000 7110.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 194 196.000000 9153.2500 0.0000
P 110 127.250000 6250.5000 6250.5000
D 0 0.000000 0.0000 0.0000
S 7 10.000000 750.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
390 324.750000 15264.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 851 811.500000 38528.5000 6250.5000