CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1042 2153.250000 79651.7500 36.9914
Subtotal (Total Children Is Unduplicated) 1042 2153.250000 79651.7500 36.9914
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 10.000000 555.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 54.000000 4050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 21 42.000000 3150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 33.500000 2512.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 86.000000 4773.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 33 66.000000 3663.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 54.000000 4050.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 58.000000 4350.0000 75.0000
Subtotal (Total Children Is Unduplicated) 140 421.500000 28375.5000 67.3203
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Total 2574.750000 108027.2500 41.9564
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Number of Children (Unduplicated) With at Least One Service 1050
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Center 07
Flag Claims Units Chgs Paid
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R 4 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 375 302.500000 11944.5000 0.0000
P 2475 2081.500000 88536.0000 88268.0000
D 2 2.500000 129.5000 0.0000
S 3 4.500000 318.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
14 9.500000 351.5000 0.0000
Other 299 172.250000 6673.2500 0.0000
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Total 3172 2574.750000 108027.2500 88268.0000