CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:TPIN
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 1 2.000000 74.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 74.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 58.000000 3690.0000 63.6207
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 10.000000 600.0000 60.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 52.000000 2775.0000 53.3654
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
Subtotal (Total Children Is Unduplicated) 29 154.000000 9459.0000 61.4221
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Total 156.000000 9533.0000 61.1090
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Number of Children (Unduplicated) With at Least One Service 29
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Center 52
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 7 14.000000 795.5900 592.5500
D 11 22.000000 1260.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 18 36.000000 2505.0000 0.0000
T 27 54.000000 3371.4100 2969.4100
15 30.000000 1601.0000 53.6100
Other 0 0.000000 0.0000 0.0000
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Total 78 156.000000 9533.0000 3615.5700