CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2022 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 2434 3243.500000 120528.5500 37.1600
TCM-T1017TL-TARGETED CASE MANAGEMENT 3279 26196.50000 973085.9500 37.1456
Subtotal (Total Children Is Unduplicated) 3319 29440.00000 1093614.5000 37.1472
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 64 69.500000 3475.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 7.000000 350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 63 51.000000 2550.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 23.500000 1762.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 17.000000 1275.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 19 23.000000 1725.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 23.000000 1715.2500 74.5761
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 22 28.000000 2070.7500 73.9554
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 26 38.000000 2109.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 41 60.000000 3330.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 333 410.000000 30730.5000 74.9524
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 306 340.000000 25500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 82 91.000000 6825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 293 323.000000 24225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 553 916.500000 50865.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 732 1169.500000 64907.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 482 707.500000 53062.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 255 363.000000 27166.5000 74.8388
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 314 315.000000 41605.8300 132.0820
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 6 6.000000 350.0500 58.3417
Subtotal (Total Children Is Unduplicated) 1465 4986.500000 345975.8800 69.3825
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Total 34426.500000 1439590.3800 41.8163
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Number of Children (Unduplicated) With at Least One Service 3329
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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 5393 8198.000000 324988.9500 0.0000
P 6338 10344.250000 420632.0000 425522.9700
D 930 1345.250000 51793.4500 0.0000
S 4 5.000000 186.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 3.250000 120.2500 0.0000
13401 14227.250000 630047.1800 0.0000
Other 2 6.250000 232.5000 0.0000
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Total 26244 34426.500000 1439590.3800 425522.9700