CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 845 796.750000 29479.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1462 6581.250000 243506.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1507 7378.000000 272986.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 17 14.750000 737.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 55 39.750000 1987.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 22 25.500000 1912.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 7.500000 562.5000 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 24 33.500000 1859.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 76 83.500000 6262.5000 75.0000
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 182 215.500000 16162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 286 521.500000 28915.5000 55.4468
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 138 177.500000 13312.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 67 67.000000 8065.6400 120.3827
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.1700 31.1700
Subtotal (Total Children Is Unduplicated) 397 1200.000000 80706.0600 67.2551
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Total 8578.000000 353692.0600 41.2325
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Number of Children (Unduplicated) With at Least One Service 1517
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Center 04
Flag Claims Units Chgs Paid
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R 11 13.000000 858.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2700 4264.000000 169388.9400 0.0000
P 644 1122.750000 41569.5000 41569.5000
D 31 36.750000 1359.7500 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
2972 3141.500000 140515.8700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6358 8578.000000 353692.0600 41569.5000