CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 73 241.250000 8870.7500 36.7699
Subtotal (Total Children Is Unduplicated) 73 241.250000 8870.7500 36.7699
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 40.000000 2220.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 16.000000 888.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 26.000000 1950.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 18.000000 1350.0000 75.0000
Subtotal (Total Children Is Unduplicated) 38 110.000000 7041.0000 64.0091
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Total 351.250000 15911.7500 45.3004
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Number of Children (Unduplicated) With at Least One Service 75
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Center 07
Flag Claims Units Chgs Paid
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R 8 9.500000 464.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 33.750000 1437.7500 0.0000
P 233 286.750000 13147.2500 13147.2500
D 0 0.000000 0.0000 0.0000
S 1 2.000000 150.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 0.750000 27.7500 0.0000
Other 20 18.500000 684.5000 0.0000
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Total 288 351.250000 15911.7500 13147.2500