CMS/EIP Fiscal Report Center: 57
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 77 542.500000 20175.0000 37.1889
Subtotal (Total Children Is Unduplicated) 77 542.500000 20175.0000 37.1889
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 38 64.500000 4837.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 23.000000 1725.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 23.000000 1725.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 61 105.500000 5855.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.500000 712.5000 75.0000
Subtotal (Total Children Is Unduplicated) 73 248.000000 16318.5000 65.8004
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.000000 400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 8.000000 400.0000 50.0000
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Total 798.500000 36893.5000 46.2035
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Number of Children (Unduplicated) With at Least One Service 78
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Center 57
Flag Claims Units Chgs Paid
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R 14 36.750000 1367.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 276 566.750000 25866.5500 0.0000
P 91 170.000000 8570.7500 8570.1500
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 7 17.000000 689.1000 596.6600
2 8.000000 400.0000 400.0000
Other 0 0.000000 0.0000 0.0000
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Total 390 798.500000 36893.5000 9566.8100