CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 40 121.000000 4500.7000 37.1959
Subtotal (Total Children Is Unduplicated) 40 121.000000 4500.7000 37.1959
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 16.500000 915.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 12 22.000000 1328.2500 60.3750
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Total 143.000000 5828.9500 40.7619
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Number of Children (Unduplicated) With at Least One Service 41
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Center 03
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 70 98.250000 3997.1500 0.0000
P 4 6.000000 259.8000 259.8000
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
1 2.000000 150.0000 0.0000
Other 33 36.750000 1422.0000 0.0000
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Total 108 143.000000 5828.9500 259.8000