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:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 11.000000 825.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 1216.0000 304.0000
Subtotal (Total Children Is Unduplicated) 12 16.500000 2153.5000 130.5152
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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 30.000000 3117.9400 103.9313
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Number of Children (Unduplicated) With at Least One Service 13
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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
15 16.500000 2153.5000 0.0000
Other 4 13.500000 964.4400 0.0000
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Total 19 30.000000 3117.9400 0.0000