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: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 39 235.000000 8695.0000 37.0000
Subtotal (Total Children Is Unduplicated) 39 235.000000 8695.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 11.500000 862.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 18.500000 1387.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 30 37.500000 2081.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 17.000000 1275.0000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 2 2.000000 60.7000 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 379.4000 63.2333
Subtotal (Total Children Is Unduplicated) 33 95.500000 6251.8500 65.4644
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Total 330.500000 14946.8500 45.2250
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Number of Children (Unduplicated) With at Least One Service 39
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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 131 209.750000 9015.0000 0.0000
P 56 85.250000 3692.5000 3692.8900
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
33 35.500000 2239.3500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 220 330.500000 14946.8500 3692.8900