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
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 148 172.000000 6364.0000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 6.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 75 156.250000 5781.2500 37.0000
Subtotal (Total Children Is Unduplicated) 159 334.250000 12145.2500 36.3358
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.766267 132.4700 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.800000 1035.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.800000 285.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 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 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 12 35.366267 2457.4700 69.4863
-----------------------------------------------------------------------------------------------------------------------
Total 369.616267 14602.7200 39.5078
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 159
-----------------------------------------------------------------------------------------------------------------------
Center 55
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 9 17.600000 1125.0000 1125.0000
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
513 352.016267 13477.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 522 369.616267 14602.7200 1125.0000