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:OTHER
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 52 73.750000 2741.2000 37.1688
Subtotal (Total Children Is Unduplicated) 52 73.750000 2741.2000 37.1688
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 29 38.500000 2887.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 30.000000 2250.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 51 69.500000 3857.2500 55.5000
Subtotal (Total Children Is Unduplicated) 54 145.000000 9519.7500 65.6534
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Total 218.750000 12260.9500 56.0501
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Number of Children (Unduplicated) With at Least One Service 55
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Center 09
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 3 5.000000 375.0000 375.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 154 209.000000 11709.2500 0.0000
T 0 0.000000 0.0000 0.0000
2 4.750000 176.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 159 218.750000 12260.9500 375.0000