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: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 1141 5078.250000 187895.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1141 5078.250000 187895.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 7.000000 525.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 18 21.000000 1575.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.000000 75.0000 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 18 22.000000 1221.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 61 66.000000 4950.0000 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 152 179.000000 13425.0000 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 230 315.000000 17482.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 74 81.500000 6112.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 1365.7200 71.8800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.1700 31.1700
Subtotal (Total Children Is Unduplicated) 267 717.500000 47059.8900 65.5887
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Total 5795.750000 234955.1400 40.5392
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Number of Children (Unduplicated) With at Least One Service 1146
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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 2699 4263.500000 169370.4400 0.0000
P 643 1122.250000 41551.0000 41551.0000
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
283 360.250000 21815.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3667 5795.750000 234955.1400 41551.0000