CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 51 206.750000 7622.0000 36.8658
Subtotal (Total Children Is Unduplicated) 51 206.750000 7622.0000 36.8658
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 24.000000 1800.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 10.500000 787.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 18 28.500000 1581.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 35 91.500000 6248.2500 68.2869
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 5.000000 250.0000 50.0000
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Total 303.250000 14120.2500 46.5631
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Number of Children (Unduplicated) With at Least One Service 52
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Center 53
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 114 126.250000 6023.7500 0.0000
P 128 147.000000 6621.7500 6621.7500
D 0 0.000000 0.0000 0.0000
S 4 3.000000 168.0000 18.5000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
15 21.250000 1094.0000 0.0000
Other 6 5.750000 212.7500 0.0000
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Total 267 303.250000 14120.2500 6640.2500