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
Agency Filter:EIP DEI DEIP
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 789 694.500000 25696.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1493 6746.500000 249391.2500 36.9660
Subtotal (Total Children Is Unduplicated) 1535 7441.000000 275087.7500 36.9692
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 14 12.250000 612.5000 50.0000
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 12 13.500000 1012.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 15.500000 1162.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 31.500000 1748.2500 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 81 89.500000 6683.2500 74.6732
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 215 266.000000 19950.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 315 581.000000 32245.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 171 305.000000 22836.0000 74.8721
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 3 3.000000 91.0500 30.3500
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 304.0000 304.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 67 67.000000 6500.3500 97.0201
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 124.8500 24.9700
Subtotal (Total Children Is Unduplicated) 363 1395.250000 93626.2500 67.1036
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Total 8836.250000 368714.0000 41.7274
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Number of Children (Unduplicated) With at Least One Service 1538
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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 2613 4335.500000 172628.5000 0.0000
P 737 1234.250000 48738.7500 48470.4700
D 9 9.000000 333.0000 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
2869 3233.000000 146107.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6241 8836.250000 368714.0000 48470.4700