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
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 1053 3867.500000 143793.0500 37.1798
Subtotal (Total Children Is Unduplicated) 1053 3867.500000 143793.0500 37.1798
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Screening, Eval, and Assessment,Class #02
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 2 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 9.000000 499.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 77 87.500000 6562.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 84 87.000000 6525.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 209 254.500000 14124.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 33.000000 2475.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 84.000000 6300.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 1066.1000 76.1500
Subtotal (Total Children Is Unduplicated) 225 576.000000 38077.8500 66.1074
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Total 4443.500000 181870.9000 40.9297
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Number of Children (Unduplicated) With at Least One Service 1062
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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 832 1350.250000 53579.5000 50430.1500
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
344 473.000000 23388.3000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2954 4443.500000 181870.9000 50430.1500