CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 Page: 1
List order: No List
Payclass Filters:OTHER
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 83.000000 3089.5000 37.2229
Subtotal (Total Children Is Unduplicated) 58 83.000000 3089.5000 37.2229
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 39 57.500000 4350.0000 75.6522
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 33.000000 2475.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 53 76.500000 4245.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 72 198.000000 13347.0000 67.4091
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Total 281.000000 16436.5000 58.4929
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Number of Children (Unduplicated) With at Least One Service 72
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Center 09
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 6 12.000000 900.0000 900.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 174 249.000000 14036.5000 0.0000
T 0 0.000000 0.0000 0.0000
3 6.000000 450.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 183 267.000000 15386.5000 900.0000
Center 55
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 4 8.000000 600.0000 600.0000
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
3 6.000000 450.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7 14.000000 1050.0000 600.0000