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
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 789 694.500000 25696.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 362 1661.500000 61364.5000 36.9332
Subtotal (Total Children Is Unduplicated) 972 2356.000000 87061.0000 36.9529
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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
Subtotal (Total Children Is Unduplicated) 242 505.250000 31851.7400 63.0415
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Total 2861.250000 118912.7400 41.5597
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Number of Children (Unduplicated) With at Least One Service 1050
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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
2612 2861.250000 118912.7400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2612 2861.250000 118912.7400 0.0000