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
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 62 89.000000 3293.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 22 121.250000 4486.2500 37.0000
Subtotal (Total Children Is Unduplicated) 68 210.250000 7779.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
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 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
Subtotal (Total Children Is Unduplicated) 11 24.500000 1487.2500 60.7041
-----------------------------------------------------------------------------------------------------------------------
Total 234.750000 9266.5000 39.4739
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 70
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
336 234.750000 9266.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 336 234.750000 9266.5000 0.0000