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:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1153 5085.000000 188026.7500 36.9767
Subtotal (Total Children Is Unduplicated) 1153 5085.000000 188026.7500 36.9767
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Screening, Eval, and Assessment,Class #02
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 8 9.000000 675.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 9.000000 675.0000 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 13 17.500000 971.2500 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 56 61.000000 4575.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 159 193.500000 14512.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 229 327.500000 18176.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 75 96.000000 7180.5000 74.7969
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 2 2.000000 60.7000 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 24 24.000000 1556.5100 64.8546
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 78.0100 26.0033
Subtotal (Total Children Is Unduplicated) 253 746.500000 48741.2200 65.2930
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Total 5831.500000 236767.9700 40.6016
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Number of Children (Unduplicated) With at Least One Service 1159
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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
180 228.250000 14161.2200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3552 5831.500000 236767.9700 48470.4700