CMS/EIP Fiscal Report Center: 52
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 15 74.750000 2691.7500 36.0100
Subtotal (Total Children Is Unduplicated) 15 74.750000 2691.7500 36.0100
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 20.000000 1500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 22.000000 1221.0000 55.5000
Subtotal (Total Children Is Unduplicated) 13 60.000000 4032.0000 67.2000
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Total 134.750000 6723.7500 49.8980
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Number of Children (Unduplicated) With at Least One Service 15
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Center 52
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 13 18.750000 1110.7500 0.0000
P 63 101.500000 4813.5000 4813.5000
D 0 0.000000 0.0000 0.0000
S 4 4.500000 166.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 10.000000 633.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 85 134.750000 6723.7500 4813.5000