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
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 930 3573.750000 132918.7000 37.1931
Subtotal (Total Children Is Unduplicated) 930 3573.750000 132918.7000 37.1931
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 135 244.500000 18308.2500 74.8804
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 31 57.000000 4275.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 28 48.500000 3637.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 175 325.500000 18065.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 27.000000 2025.0000 75.0000
Subtotal (Total Children Is Unduplicated) 204 742.000000 48873.7500 65.8676
-----------------------------------------------------------------------------------------------------------------------
Total 4315.750000 181792.4500 42.1230
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 932
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 134 177.000000 6584.4000 0.0000
U 0 0.000000 0.0000 0.0000
B 1781 2491.750000 105369.9500 0.0000
P 814 1229.250000 54298.4500 54289.4560
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 81 121.250000 4510.5000 4486.3000
6 11.500000 427.8000 0.0000
Other 259 285.000000 10601.3500 0.0000
---------------------------------------------------------
Total 3075 4315.750000 181792.4500 58775.7560