CMS/EIP Fiscal Report Center: 53
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 69 304.750000 11275.7500 37.0000
Subtotal (Total Children Is Unduplicated) 69 304.750000 11275.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 24 36.000000 2700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 21 33.000000 2475.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 17.500000 1312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 35 52.500000 2913.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 14.000000 1050.0000 75.0000
Subtotal (Total Children Is Unduplicated) 65 167.000000 11345.2500 67.9356
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Total 471.750000 22621.0000 47.9512
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Number of Children (Unduplicated) With at Least One Service 71
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Center 53
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 163 192.750000 9204.5000 0.0000
P 85 107.000000 4683.7500 4683.7500
D 0 0.000000 0.0000 0.0000
S 2 3.500000 186.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
116 149.500000 7806.2500 0.0000
Other 25 19.000000 740.0000 0.0000
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Total 391 471.750000 22621.0000 4683.7500