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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 6.500000 468.0000 72.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 27.500000 2062.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 37.500000 2812.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 3648.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 386.0000 193.0000
Subtotal (Total Children Is Unduplicated) 63 91.000000 9696.2500 106.5522
-----------------------------------------------------------------------------------------------------------------------
Total 91.000000 9696.2500 106.5522
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 63
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 5 6.000000 679.0000 1090.6700
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
76 85.000000 9017.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 81 91.000000 9696.2500 1090.6700