CMS/EIP Fiscal Report Center: 52
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 18 75.750000 2817.1500 37.1901
Subtotal (Total Children Is Unduplicated) 18 75.750000 2817.1500 37.1901
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 30.000000 2250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 24.000000 1332.0000 55.5000
Subtotal (Total Children Is Unduplicated) 15 68.000000 4632.0000 68.1176
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Total 143.750000 7449.1500 51.8202
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Number of Children (Unduplicated) With at Least One Service 18
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Center 52
Flag Claims Units Chgs Paid
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R 2 4.000000 261.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 58.750000 3123.9500 0.0000
P 38 56.750000 2898.7000 2897.9000
D 0 0.000000 0.0000 0.0000
S 21 15.750000 585.9000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5 8.500000 579.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 106 143.750000 7449.1500 2897.9000