CMS/EIP Fiscal Report Center: 09
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 49 157.000000 5836.0500 37.1723
Subtotal (Total Children Is Unduplicated) 49 157.000000 5836.0500 37.1723
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 26 47.000000 3525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 26.000000 1950.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 36 65.500000 3635.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 13.000000 975.0000 75.0000
Subtotal (Total Children Is Unduplicated) 45 169.000000 11368.5000 67.2692
-----------------------------------------------------------------------------------------------------------------------
Total 326.000000 17204.5500 52.7747
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 52
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 66 100.000000 4652.2000 166.8000
P 80 133.500000 5985.3500 5872.5500
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
20 38.500000 2887.5000 0.0000
Other 28 52.000000 3568.5000 0.0000
---------------------------------------------------------
Total 195 326.000000 17204.5500 6039.3500