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
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 845 796.750000 29479.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 337 1503.000000 55611.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1009 2299.750000 85090.7500 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 1 1.000000 75.0000 75.0000
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 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 11.500000 638.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 14 16.500000 1237.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 29 35.500000 2662.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 164 202.000000 11183.2500 55.3626
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 57.000000 4275.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 34 34.000000 2443.9200 71.8800
Subtotal (Total Children Is Unduplicated) 278 418.000000 25690.4200 61.4603
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Total 2717.750000 110781.1700 40.7621
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Number of Children (Unduplicated) With at Least One Service 1109
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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 1 0.500000 18.5000 0.0000
P 1 0.500000 18.5000 18.5000
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
2630 2716.750000 110744.1700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2632 2717.750000 110781.1700 18.5000