CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 1217 5262.500000 194712.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1217 5262.500000 194712.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 44 46.000000 3450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 96 115.000000 8625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 162 221.500000 12293.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 63.000000 4725.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 1006.3200 71.8800
Subtotal (Total Children Is Unduplicated) 170 467.000000 30564.5700 65.4488
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 1 0.500000 35.7200 71.4400
Subtotal (Total Children Is Unduplicated) 1 0.500000 35.7200 71.4400
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Total 5730.000000 225312.7900 39.3216
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Number of Children (Unduplicated) With at Least One Service 1220
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Center 04
Flag Claims Units Chgs Paid
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R 13 17.000000 1044.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2921 4558.750000 181516.5700 0.0000
P 662 1154.250000 42752.2200 42716.5000
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 3596 5730.000000 225312.7900 42716.5000