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:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 49 243.000000 9039.6000 37.2000
Subtotal (Total Children Is Unduplicated) 49 243.000000 9039.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 18 19.500000 1462.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 8.000000 600.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 39 45.500000 2525.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 9.000000 675.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 9.500000 712.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 228.4500 76.1500
Subtotal (Total Children Is Unduplicated) 40 94.500000 6203.7000 65.6476
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 4.000000 200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
Subtotal (Total Children Is Unduplicated) 3 8.000000 487.8400 60.9800
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Total 345.500000 15731.1400 45.5315
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Number of Children (Unduplicated) With at Least One Service 51
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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 48 81.000000 3433.9500 3375.7500
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
48 52.500000 3211.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 231 345.500000 15731.1400 3375.7500