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
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 1220 5358.000000 198127.7500 36.9779
Subtotal (Total Children Is Unduplicated) 1220 5358.000000 198127.7500 36.9779
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 56 61.500000 4612.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 134 160.000000 12000.0000 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 196 274.000000 15207.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 67 87.000000 6505.5000 74.7759
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 212 597.500000 39318.8000 65.8055
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EI Services,Class #03
PHY-97110-PT SESSION BY LICENSED PT 2 12.500000 893.0000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 3.500000 250.0400 71.4400
Subtotal (Total Children Is Unduplicated) 4 16.000000 1143.0400 71.4400
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Total 5971.500000 238589.5900 39.9547
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Number of Children (Unduplicated) With at Least One Service 1225
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Center 04
Flag Claims Units Chgs Paid
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R 13 24.500000 906.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2792 4585.000000 183114.2500 0.0000
P 828 1362.000000 54568.8400 53062.4600
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 3633 5971.500000 238589.5900 53062.4600