CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 784 3269.500000 120453.5000 36.8416
Subtotal (Total Children Is Unduplicated) 784 3269.500000 120453.5000 36.8416
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 12.500000 937.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 10.500000 758.2500 72.2143
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 10 17.500000 971.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 107 168.000000 12570.7500 74.8259
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 23 38.000000 2797.5000 73.6184
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 31 48.000000 3600.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 136 217.000000 12043.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 37.000000 2760.0000 74.5946
Subtotal (Total Children Is Unduplicated) 180 566.000000 37722.0000 66.6466
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Total 3835.500000 158175.5000 41.2399
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Number of Children (Unduplicated) With at Least One Service 788
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Center 57
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 725 955.500000 40454.7500 0.0000
P 2072 2771.750000 113867.5000 113939.1500
D 0 0.000000 0.0000 0.0000
S 1 1.500000 112.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 34 104.000000 3639.0000 2577.9500
1 0.500000 18.5000 0.0000
Other 2 1.750000 64.7500 0.0000
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Total 2836 3835.500000 158175.5000 116517.1000