CMS/EIP Fiscal Report Center: 10
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 74 316.250000 11764.4000 37.1997
Subtotal (Total Children Is Unduplicated) 74 316.250000 11764.4000 37.1997
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 21.000000 1575.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 25 45.000000 3375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 26.500000 1987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 29.500000 1637.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 23 40.000000 2220.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.000000 750.0000 75.0000
Subtotal (Total Children Is Unduplicated) 53 200.500000 13682.2500 68.2406
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Total 516.750000 25446.6500 49.2436
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Number of Children (Unduplicated) With at Least One Service 79
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Center 10
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 384 486.500000 24001.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 8 12.500000 672.9000 0.0000
S 4 7.250000 269.7000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 4.000000 261.0000 0.0000
Other 5 6.500000 241.8000 0.0000
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Total 403 516.750000 25446.6500 0.0000