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:GR
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 22 147.250000 5448.2500 37.0000
Subtotal (Total Children Is Unduplicated) 40 166.750000 6169.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 11.000000 825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 7.000000 525.0000 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 31 39.000000 2164.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 16.500000 1237.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 287.5200 71.8800
Subtotal (Total Children Is Unduplicated) 36 82.500000 5317.0200 64.4487
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Total 249.250000 11486.7700 46.0853
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Number of Children (Unduplicated) With at Least One Service 44
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Center 04
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
198 249.250000 11486.7700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 198 249.250000 11486.7700 0.0000