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
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 170 1245.000000 46253.5500 37.1514
Subtotal (Total Children Is Unduplicated) 170 1245.000000 46253.5500 37.1514
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 47.500000 3562.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 46 49.500000 3712.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 14.500000 1087.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 21 20.500000 1537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 75 90.500000 5022.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 85 99.000000 5494.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 53.000000 3975.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 27.500000 2062.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 224.1800 74.7267
Subtotal (Total Children Is Unduplicated) 167 412.500000 27163.4300 65.8507
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Total 1657.500000 73416.9800 44.2938
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Number of Children (Unduplicated) With at Least One Service 181
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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 440 673.500000 28496.2000 0.0000
P 500 800.750000 34311.5000 33988.0000
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
108 123.500000 8027.6800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1091 1657.500000 73416.9800 33988.0000