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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 700 1645.500000 61207.5500 37.1969
Subtotal (Total Children Is Unduplicated) 700 1645.500000 61207.5500 37.1969
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 81.000000 4495.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.500000 1687.5000 75.0000
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 72 124.000000 7353.5000 59.3024
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 45.000000 2250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 11 45.000000 2250.0000 50.0000
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Total 1814.500000 70811.0500 39.0251
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Number of Children (Unduplicated) With at Least One Service 714
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Center 03
Flag Claims Units Chgs Paid
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R 46 27.500000 1023.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2134 1542.500000 59636.0000 0.0000
P 43 51.750000 2316.5500 2316.5500
D 3 4.250000 214.8000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 150.0000
T 0 0.000000 0.0000 0.0000
10 12.000000 686.0000 0.0000
Other 165 174.500000 6784.7000 0.0000
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Total 2402 1814.500000 70811.0500 2466.5500