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
Payclass Filters:GR
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 36 164.500000 6119.4000 37.2000
Subtotal (Total Children Is Unduplicated) 59 187.500000 6975.0000 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 9 10.500000 787.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 11.000000 825.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 38 47.500000 2636.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 3.500000 262.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 12.500000 937.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 380.7500 76.1500
Subtotal (Total Children Is Unduplicated) 45 90.500000 5854.5000 64.6906
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 8.000000 80.0000 10.0000
Subtotal (Total Children Is Unduplicated) 3 8.000000 80.0000 10.0000
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Total 286.000000 12909.5000 45.1381
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Number of Children (Unduplicated) With at Least One Service 68
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Center 04
Flag Claims Units Chgs Paid
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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 3 8.000000 80.0000 80.0000
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
247 278.000000 12829.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 250 286.000000 12909.5000 80.0000