CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 709 578.500000 21520.2000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1422 5346.250000 198783.3500 37.1818
Subtotal (Total Children Is Unduplicated) 1474 5924.750000 220303.5500 37.1836
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 22 19.750000 987.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 12 8.000000 400.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 3.500000 262.5000 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 7 10.000000 720.7500 72.0750
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 0.500000 27.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 21.500000 1193.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 102 117.000000 8775.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 121 128.500000 9637.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 287 458.000000 25419.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 57 75.000000 5625.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 110 150.000000 11250.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 67 67.000000 7836.2500 116.9590
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 417.4700 139.1567
Subtotal (Total Children Is Unduplicated) 343 1066.250000 72889.4700 68.3606
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Total 6991.000000 293193.0200 41.9386
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Number of Children (Unduplicated) With at Least One Service 1482
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Center 04
Flag Claims Units Chgs Paid
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R 81 111.750000 4363.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 1642 2438.250000 97706.4000 0.0000
P 837 1356.250000 54258.5000 51520.8200
D 54 69.500000 2805.0000 0.0000
S 1 0.750000 27.9000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2939 3014.500000 134031.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5554 6991.000000 293193.0200 51520.8200