CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 122 300.750000 11127.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 67 198.500000 7344.5000 37.0000
Subtotal (Total Children Is Unduplicated) 127 499.250000 18472.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 28.000000 2100.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 20.000000 1500.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 19 32.500000 2437.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 37.500000 2081.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 43 127.500000 8753.2500 68.6529
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
INTR-T1013-INTERPRETER 8 32.250000 1612.5000 50.0000
Subtotal (Total Children Is Unduplicated) 8 32.250000 1612.5000 50.0000
-----------------------------------------------------------------------------------------------------------------------
Total 659.000000 28838.0000 43.7602
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 128
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 478 655.000000 28577.0000 28577.0000
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
0 0.000000 0.0000 0.0000
Other 2 4.000000 261.0000 0.0000
---------------------------------------------------------
Total 480 659.000000 28838.0000 28577.0000