CMS/EIP Fiscal Report Center: 07
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 878 1849.000000 68385.2500 36.9850
Subtotal (Total Children Is Unduplicated) 878 1849.000000 68385.2500 36.9850
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 84.000000 6300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 30.000000 2250.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 61 122.000000 6771.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 69 137.500000 7631.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 94.000000 7050.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 118.000000 8850.0000 75.0000
Subtotal (Total Children Is Unduplicated) 205 607.500000 40307.2500 66.3494
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Total 2456.500000 108692.5000 44.2469
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Number of Children (Unduplicated) With at Least One Service 913
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Center 07
Flag Claims Units Chgs Paid
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R 93 84.750000 3135.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 993 966.750000 45570.5000 0.0000
P 1549 1374.250000 58848.5000 58716.9000
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.250000 9.2500 0.0000
9 5.750000 212.7500 0.0000
Other 50 24.500000 906.5000 0.0000
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Total 2696 2456.500000 108692.5000 58716.9000