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
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 33 23.000000 855.6000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 82 407.500000 15159.0000 37.2000
Subtotal (Total Children Is Unduplicated) 82 430.500000 16014.6000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 0.500000 25.0000 50.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 27 30.000000 2250.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 19.000000 1425.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 64 94.500000 5244.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 21.000000 1575.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 39.000000 2925.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 2509.3500 167.2900
Subtotal (Total Children Is Unduplicated) 67 219.000000 15954.1000 72.8498
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 4.000000 200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 8.000000 80.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
Subtotal (Total Children Is Unduplicated) 3 16.000000 567.8400 35.4900
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Total 665.500000 32536.5400 48.8904
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Number of Children (Unduplicated) With at Least One Service 82
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Center 04
Flag Claims Units Chgs Paid
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R 4 6.000000 298.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 126 196.750000 8252.1000 0.0000
P 53 91.500000 3701.4500 3965.5500
D 2 1.250000 46.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 8.000000 487.8400 0.0000
T 0 0.000000 0.0000 0.0000
325 362.000000 19749.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 513 665.500000 32536.5400 3965.5500