CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2022 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 169 186.000000 6909.2000 37.1462
TCM-T1017TL-TARGETED CASE MANAGEMENT 283 2239.750000 83205.7500 37.1496
Subtotal (Total Children Is Unduplicated) 283 2425.750000 90114.9500 37.1493
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.500000 416.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 69 76.000000 5700.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 75 83.000000 6225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 20.500000 1537.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 41 46.500000 3487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 115 181.000000 10045.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 147 221.000000 12265.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 100 143.500000 10762.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 92.000000 6900.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 68 68.000000 9223.9900 135.6469
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
Subtotal (Total Children Is Unduplicated) 268 956.000000 67898.2400 71.0233
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Total 3381.750000 158013.1900 46.7253
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Number of Children (Unduplicated) With at Least One Service 283
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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 441 674.250000 28523.9500 0.0000
P 530 832.750000 37627.5000 40339.7100
D 36 49.750000 1985.2000 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
1521 1815.000000 89280.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2535 3381.750000 158013.1900 40339.7100