CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 893 3322.000000 123506.0000 37.1782
Subtotal (Total Children Is Unduplicated) 893 3322.000000 123506.0000 37.1782
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 43 60.500000 4537.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 23.500000 1762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 67 95.500000 5300.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 54.000000 4050.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 77 236.000000 15784.9100 66.8852
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Total 3558.000000 139290.9100 39.1487
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Number of Children (Unduplicated) With at Least One Service 898
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Center 04
Flag Claims Units Chgs Paid
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R 89 159.500000 6597.4500 0.0000
U 0 0.000000 0.0000 0.0000
B 1379 2309.250000 90570.0000 0.0000
P 674 1089.250000 42123.4600 41388.0500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2142 3558.000000 139290.9100 41388.0500