CMS/EIP Fiscal Report Center: 57
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 60 389.000000 14368.9500 36.9382
Subtotal (Total Children Is Unduplicated) 60 389.000000 14368.9500 36.9382
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 34 52.000000 3870.7500 74.4375
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 26.500000 1909.5000 72.0566
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 15.500000 1133.2500 73.1129
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 48 77.000000 4273.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 12.500000 937.5000 75.0000
Subtotal (Total Children Is Unduplicated) 62 195.000000 12889.5000 66.1000
-----------------------------------------------------------------------------------------------------------------------
Total 584.000000 27258.4500 46.6754
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 68
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 112 214.250000 9352.5000 0.0000
P 197 356.750000 17383.2500 17383.2500
D 0 0.000000 0.0000 0.0000
S 1 1.500000 83.2500 83.2500
H 0 0.000000 0.0000 0.0000
T 2 3.750000 176.7500 20.3500
2 7.750000 262.7000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 314 584.000000 27258.4500 17486.8500