CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1064 3779.500000 140519.4500 37.1794
Subtotal (Total Children Is Unduplicated) 1064 3779.500000 140519.4500 37.1794
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
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 2 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 61 69.500000 5212.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 67 69.500000 5212.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 162 196.500000 10905.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 27.500000 2062.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 49.500000 3712.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 380.7500 76.1500
Subtotal (Total Children Is Unduplicated) 182 421.500000 27747.5000 65.8304
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 8.000000 575.6800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 4.500000 323.8200 71.9600
Subtotal (Total Children Is Unduplicated) 4 17.500000 1149.5000 65.6857
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Total 4218.500000 169416.4500 40.1604
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Number of Children (Unduplicated) With at Least One Service 1071
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Center 04
Flag Claims Units Chgs Paid
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R 86 118.000000 4671.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 1783 2648.500000 106460.7000 0.0000
P 891 1452.000000 58283.8500 53956.7500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2760 4218.500000 169416.4500 53956.7500