CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 771 786.000000 29239.2000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1460 6588.000000 245073.6000 37.2000
Subtotal (Total Children Is Unduplicated) 1496 7374.000000 274312.8000 37.2000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 5 5.000000 250.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 7.000000 350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 12 9.500000 475.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 16.500000 1237.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 23.000000 1276.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 204 262.000000 19650.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 276 491.500000 27278.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 198 319.500000 23962.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 81 81.000000 10497.3000 129.5963
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
Subtotal (Total Children Is Unduplicated) 331 1247.500000 87371.0200 70.0369
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Total 8621.500000 361683.8200 41.9514
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Number of Children (Unduplicated) With at Least One Service 1500
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Center 04
Flag Claims Units Chgs Paid
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R 174 297.250000 11590.0500 0.0000
U 0 0.000000 0.0000 0.0000
B 1849 3046.250000 118327.8000 0.0000
P 679 1156.500000 45718.8000 45696.5000
D 200 320.500000 12100.6500 0.0000
S 3 4.250000 158.1000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3272 3796.750000 173788.4200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6177 8621.500000 361683.8200 45696.5000