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
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 2427 18504.25000 687319.9000 37.1439
Subtotal (Total Children Is Unduplicated) 2427 18504.25000 687319.9000 37.1439
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 18.500000 1387.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 13 15.000000 1125.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 7.500000 552.7500 73.7000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 22.000000 1221.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 24 27.000000 1498.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 233 277.500000 20812.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 218 237.500000 17812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 60 63.500000 4762.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 221 237.000000 17775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 357 455.000000 25252.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 526 644.000000 35742.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 283 359.500000 26962.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 144 169.500000 12712.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 1425.5000 75.0263
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.1700 31.1700
Subtotal (Total Children Is Unduplicated) 974 2575.000000 170685.9200 66.2858
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Total 21079.250000 858005.8200 40.7038
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Number of Children (Unduplicated) With at Least One Service 2456
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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 6234 10227.750000 406264.8000 405521.2300
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 1 3.000000 111.0000 0.0000
825 996.750000 62839.0700 0.0000
Other 2 6.250000 232.5000 0.0000
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Total 13563 21079.250000 858005.8200 405521.2300