CMS/EIP Fiscal Report Center: 07
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 859 1628.250000 60616.9500 37.2283
Subtotal (Total Children Is Unduplicated) 859 1628.250000 60616.9500 37.2283
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 74.000000 5550.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 34.000000 2550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 38 76.000000 5700.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 22.000000 1650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 34 68.000000 5100.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 22.000000 1650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 65 130.000000 7126.2000 54.8169
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 32 64.000000 3552.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 60.000000 4413.3000 73.5550
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
SCREEN-T1023-SCREENING 2 2.000000 200.0000 100.0000
Subtotal (Total Children Is Unduplicated) 187 596.000000 40401.5000 67.7878
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Total 2224.250000 101018.4500 45.4169
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Number of Children (Unduplicated) With at Least One Service 885
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Center 07
Flag Claims Units Chgs Paid
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R 59 38.750000 1478.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 746 642.500000 30023.3000 0.0000
P 1806 1516.250000 68521.9500 68484.7500
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
3 2.500000 93.0000 0.0000
Other 49 24.250000 902.1000 0.0000
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Total 2663 2224.250000 101018.4500 68484.7500