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:MED
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 58 317.750000 11710.5000 36.8544
Subtotal (Total Children Is Unduplicated) 58 317.750000 11710.5000 36.8544
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 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 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 31 52.000000 3900.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 25.000000 1875.0000 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 15 23.000000 1725.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 40 74.000000 4107.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 19.500000 1462.5000 75.0000
Subtotal (Total Children Is Unduplicated) 53 207.500000 14012.2500 67.5289
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Total 525.250000 25722.7500 48.9724
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Number of Children (Unduplicated) With at Least One Service 58
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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
23 38.500000 2458.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 484 525.250000 25722.7500 6250.5000