CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 75 110.750000 4097.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 25 72.500000 2682.5000 37.0000
Subtotal (Total Children Is Unduplicated) 79 183.250000 6780.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
Subtotal (Total Children Is Unduplicated) 10 25.000000 1719.0000 68.7600
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 1 0.500000 18.5000 37.0000
Subtotal (Total Children Is Unduplicated) 2 1.500000 68.5000 45.6667
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Total 209.750000 8567.7500 40.8474
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Number of Children (Unduplicated) With at Least One Service 79
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 21 9.250000 342.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 2 3.000000 166.5000 166.5000
290 196.500000 8022.0000 0.0000
Other 1 1.000000 37.0000 0.0000
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Total 314 209.750000 8567.7500 166.5000