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
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 17 27.500000 1023.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 40 258.250000 9606.9000 37.2000
Subtotal (Total Children Is Unduplicated) 40 285.750000 10629.9000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 12.500000 937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 14.500000 1087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 19 36.500000 2025.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 16.000000 1200.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 532.4500 133.1125
Subtotal (Total Children Is Unduplicated) 30 109.000000 7446.4500 68.3161
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Total 394.750000 18076.3500 45.7919
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Number of Children (Unduplicated) With at Least One Service 42
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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 54 94.250000 3908.5500 0.0000
P 34 56.250000 2270.5500 2270.5500
D 1 1.000000 75.0000 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
168 241.750000 11766.4500 0.0000
Other 1 1.500000 55.8000 0.0000
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Total 258 394.750000 18076.3500 2270.5500