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
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 1061 4663.500000 173482.2000 37.2000
Subtotal (Total Children Is Unduplicated) 1061 4663.500000 173482.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 15.500000 860.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 140 174.500000 13087.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 182 249.500000 13847.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 120 179.000000 13425.0000 75.0000
Subtotal (Total Children Is Unduplicated) 219 646.500000 43320.0000 67.0070
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Total 5310.000000 216802.2000 40.8290
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Number of Children (Unduplicated) With at Least One Service 1067
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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 1849 3046.250000 118327.8000 0.0000
P 678 1155.500000 45681.6000 45603.5000
D 200 320.500000 12100.6500 0.0000
S 3 4.250000 158.1000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
354 486.250000 28944.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3258 5310.000000 216802.2000 45603.5000