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
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 836 3561.500000 131516.5000 36.9273
Subtotal (Total Children Is Unduplicated) 836 3561.500000 131516.5000 36.9273
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 12.000000 870.7500 72.5625
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 21.000000 1165.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 135 210.500000 15690.0000 74.5368
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 30 48.000000 3600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 41 60.500000 4537.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 176 275.500000 15290.2500 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 32 47.500000 3533.2500 74.3842
Subtotal (Total Children Is Unduplicated) 233 712.500000 47441.2500 66.5842
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Total 4274.000000 178957.7500 41.8713
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Number of Children (Unduplicated) With at Least One Service 843
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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 780 1051.750000 45074.2500 0.0000
P 2303 3221.750000 133865.0000 133982.9000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3084 4274.000000 178957.7500 133982.9000