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: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 156 984.500000 36344.2500 36.9165
Subtotal (Total Children Is Unduplicated) 156 984.500000 36344.2500 36.9165
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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 4 7.000000 525.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 59 102.500000 7687.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 43 73.500000 5473.5000 74.4694
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 42 68.500000 5137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 114 214.000100 11877.0055 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 83.500000 6262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 152 583.000100 39259.5055 67.3405
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EI Services,Class #03
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 1 1.000000 71.4400 71.4400
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Total 1568.500100 75675.1955 48.2469
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Number of Children (Unduplicated) With at Least One Service 156
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Center 53
Flag Claims Units Chgs Paid
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R 153 158.000000 7277.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 286 283.000000 13159.0000 0.0000
P 948 988.750100 46408.2555 46408.2900
D 14 17.500000 988.5000 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
67 111.000000 7083.1900 0.0000
Other 1 0.250000 9.2500 9.2500
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Total 1476 1568.500100 75675.1955 46417.5400