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
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 29 220.500000 8158.5000 37.0000
Subtotal (Total Children Is Unduplicated) 29 220.500000 8158.5000 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 8 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 12.500000 937.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 27.500000 1526.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 9.500000 712.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 71.8800 71.8800
Subtotal (Total Children Is Unduplicated) 23 62.000000 4071.6300 65.6715
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Total 282.500000 12230.1300 43.2925
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Number of Children (Unduplicated) With at Least One Service 29
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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
16 19.500000 1239.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 166 282.500000 12230.1300 1165.5000