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:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 797 699.000000 25863.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 375 1678.500000 61993.5000 36.9339
Subtotal (Total Children Is Unduplicated) 989 2377.500000 87856.5000 36.9533
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 14 12.250000 612.5000 50.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 14.000000 777.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 25 28.500000 2108.2500 73.9737
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 56 72.500000 5437.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 182 253.500000 14069.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 60 78.500000 5868.0000 74.7516
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 1 1.000000 30.3500 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 32 32.000000 2077.0500 64.9078
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 46.8400 23.4200
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 246 512.250000 32209.0900 62.8777
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 31 49.750000 2487.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 181 1565.750000 78287.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 77.750000 3887.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1016 9475.000000 94750.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 28.000000 2000.3200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 7 41.750000 2388.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 5.000000 357.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 29.000000 1657.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 29.500000 2107.4800 71.4400
Subtotal (Total Children Is Unduplicated) 1070 11301.50000 187923.2400 16.6282
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Total 14191.250000 307988.8300 21.7027
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Number of Children (Unduplicated) With at Least One Service 1615
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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 3138 11234.500000 186908.8700 186898.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 43.000000 430.0000 430.0000
T 0 0.000000 0.0000 0.0000
2644 2882.750000 119708.2400 0.0000
Other 11 31.000000 941.7200 941.7200
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Total 5805 14191.250000 307988.8300 188270.5900