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
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 63 371.500000 13745.5000 37.0000
Subtotal (Total Children Is Unduplicated) 64 396.000000 14652.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.000000 222.0000 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 28 29.500000 2212.5000 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 44 69.000000 3829.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 43.000000 3225.0000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 2 2.000000 60.7000 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 2085.5900 122.6818
Subtotal (Total Children Is Unduplicated) 50 181.500000 12910.2900 71.1311
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 7.000000 500.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 6.500000 464.3600 71.4400
Subtotal (Total Children Is Unduplicated) 1 13.500000 964.4400 71.4400
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Total 591.000000 28526.7300 48.2686
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Number of Children (Unduplicated) With at Least One Service 64
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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
232 282.500000 14854.7900 0.0000
Other 4 13.500000 964.4400 0.0000
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Total 423 591.000000 28526.7300 3692.8900