CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 39 43.750000 1627.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 77 468.750000 17437.5000 37.2000
Subtotal (Total Children Is Unduplicated) 77 512.500000 19065.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 51.000000 3825.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 100.000000 5550.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 50.500000 3787.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 2889.5000 169.9706
Subtotal (Total Children Is Unduplicated) 64 233.000000 17022.5000 73.0579
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Total 745.500000 36087.5000 48.4071
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Number of Children (Unduplicated) With at Least One Service 77
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Center 04
Flag Claims Units Chgs Paid
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R 7 10.000000 596.4000 0.0000
U 0 0.000000 0.0000 0.0000
B 113 175.500000 7238.4000 0.0000
P 55 84.500000 3648.9000 3647.6000
D 9 13.250000 492.9000 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
348 462.250000 24110.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 532 745.500000 36087.5000 3647.6000