CMS/EIP Fiscal Report Center: 55
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 148 172.000000 6364.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 6.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 150 589.500000 21811.5000 37.0000
Subtotal (Total Children Is Unduplicated) 163 767.500000 28175.5000 36.7107
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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 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 106 214.000000 16050.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 19 38.000000 2850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 43 90.000000 6750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 48 96.000000 5328.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 126 486.000000 34344.0000 70.6667
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Total 1253.500000 62519.5000 49.8759
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Number of Children (Unduplicated) With at Least One Service 163
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Center 55
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 475 596.500000 28181.5000 0.0000
P 17 33.600000 2325.0000 2325.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 11 22.000000 1650.0000 0.0000
T 0 0.000000 0.0000 0.0000
644 601.400000 30363.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1147 1253.500000 62519.5000 2325.0000