CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 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 192 379.750000 14023.0000 36.9269
TCM-T1017TL-TARGETED CASE MANAGEMENT 84 398.250000 14716.7500 36.9535
Subtotal (Total Children Is Unduplicated) 206 778.000000 28739.7500 36.9406
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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 12 19.000000 950.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 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 11 18.000000 1350.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 4.000000 300.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 22 34.499900 1914.7445 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 42 104.999900 6622.9945 63.0762
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 50.0000 50.0000
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Total 883.999900 35412.7445 40.0597
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Number of Children (Unduplicated) With at Least One Service 207
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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 7 3.750000 166.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 10 14.500000 867.5000 867.5000
1275 865.749900 34378.7445 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1292 883.999900 35412.7445 867.5000