CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 32 24.500000 906.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 25 136.500000 5050.5000 37.0000
Subtotal (Total Children Is Unduplicated) 42 161.000000 5957.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 3.000000 166.5000 55.5000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 11.000000 825.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 26 31.500000 1748.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 15.000000 1125.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 490.1900 70.0271
Subtotal (Total Children Is Unduplicated) 38 69.500000 4504.9400 64.8193
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Total 230.500000 10461.9400 45.3880
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Number of Children (Unduplicated) With at Least One Service 56
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Center 04
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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 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
184 230.500000 10461.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 184 230.500000 10461.9400 0.0000