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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1115 2395.500000 88559.5000 36.9691
Subtotal (Total Children Is Unduplicated) 1115 2395.500000 88559.5000 36.9691
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 16.000000 888.0000 55.5000
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 28 56.000000 4200.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 21 42.000000 3150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 33.500000 2512.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 126.000000 6993.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 41 82.000000 4551.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 80.000000 6000.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 76.000000 5700.0000 75.0000
Subtotal (Total Children Is Unduplicated) 178 531.500000 35416.5000 66.6350
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Total 2927.000000 123976.0000 42.3560
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Number of Children (Unduplicated) With at Least One Service 1125
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Center 07
Flag Claims Units Chgs Paid
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R 12 11.500000 538.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 399 336.250000 13382.2500 0.0000
P 2713 2369.250000 101720.2500 101452.2500
D 2 2.500000 129.5000 0.0000
S 4 6.500000 468.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16 10.250000 379.2500 0.0000
Other 319 190.750000 7357.7500 0.0000
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Total 3465 2927.000000 123976.0000 101452.2500