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
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 2434 3243.500000 120528.5500 37.1600
TCM-T1017TL-TARGETED CASE MANAGEMENT 1095 7692.250000 285766.0500 37.1499
Subtotal (Total Children Is Unduplicated) 2811 10935.75000 406294.6000 37.1529
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 63 66.000000 3300.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 6.500000 325.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 63 51.000000 2550.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 5.000000 375.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 6.500000 487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 7.500000 552.7500 73.7000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 8.500000 471.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 20 27.000000 1498.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 88 119.000000 8925.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 87 101.500000 7612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 26.500000 1987.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 71 85.000000 6375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 143 211.000000 11710.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 353 455.000000 25252.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 104 123.000000 9225.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 75 102.000000 7620.7500 74.7132
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 78 78.000000 5820.1400 74.6172
Subtotal (Total Children Is Unduplicated) 681 1492.000000 95064.3900 63.7161
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Total 12427.750000 501358.9900 40.3419
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Number of Children (Unduplicated) With at Least One Service 2859
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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 0 0.000000 0.0000 0.0000
P 5 3.000000 129.7000 167.0000
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 1 0.250000 9.2500 0.0000
11760 12424.500000 501220.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11766 12427.750000 501358.9900 167.0000