CMS/EIP Fiscal Report Center: 57
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 1905 2667.750000 99143.1500 37.1636
TCM-T1017TL-TARGETED CASE MANAGEMENT 1024 9130.750000 339210.8000 37.1504
Subtotal (Total Children Is Unduplicated) 2257 11798.50000 438353.9500 37.1534
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 33 74.000000 3700.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 19 36.000000 2700.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 24 46.500000 2580.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 118 217.000000 16225.0000 74.7696
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 23 44.500000 3337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 35.000000 2625.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 155 291.000000 16100.5000 55.3282
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 21.500000 1612.5000 75.0000
Subtotal (Total Children Is Unduplicated) 218 780.000000 49968.7500 64.0625
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EI Services,Class #03
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 8.000000 400.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 2 9.000000 450.0000 50.0000
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Total 12587.500000 488772.7000 38.8300
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Number of Children (Unduplicated) With at Least One Service 2261
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Center 57
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 1 2.000000 150.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 15 20.000000 854.6500 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
12653 12564.000000 487712.2500 0.0000
Other 2 1.500000 55.8000 0.0000
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Total 12671 12587.500000 488772.7000 0.0000