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
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 29 19.500000 721.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 51 367.750000 13606.7500 37.0000
Subtotal (Total Children Is Unduplicated) 51 387.250000 14328.2500 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 18 19.000000 1425.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 5.000000 277.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 41 66.500000 3690.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 45.000000 3375.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 3095.4000 221.1000
Subtotal (Total Children Is Unduplicated) 46 172.500000 13549.6500 78.5487
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Total 559.750000 27877.9000 49.8042
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Number of Children (Unduplicated) With at Least One Service 52
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Center 04
Flag Claims Units Chgs Paid
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R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 129 226.750000 9611.6300 0.0000
P 18 31.500000 1165.5000 1165.5000
D 2 3.750000 138.7500 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
241 296.750000 16887.0200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 391 559.750000 27877.9000 1165.5000