CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
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 47 32.000000 1184.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 4.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 109 586.750000 21709.7500 37.0000
Subtotal (Total Children Is Unduplicated) 109 623.000000 22893.7500 36.7476
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 37.500000 2812.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 34 58.000000 4350.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 16 28.000000 2100.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 40 70.000000 3885.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 51.500000 3862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 79 277.500000 19301.2500 69.5541
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Total 900.500000 42195.0000 46.8573
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Number of Children (Unduplicated) With at Least One Service 109
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Center 54
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 297 334.750000 15447.5000 150.0000
P 109 140.750000 6645.7500 6645.7500
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 8 14.100000 938.5000 938.5000
387 403.150000 18763.5000 0.0000
Other 9 5.750000 249.7500 0.0000
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Total 811 900.500000 42195.0000 7734.2500