CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 59 177.750000 6612.3000 37.2000
Subtotal (Total Children Is Unduplicated) 59 177.750000 6612.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 31 57.500000 4283.2500 74.4913
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 34.500000 2587.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 26.000000 1950.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 37 68.000000 3774.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
Subtotal (Total Children Is Unduplicated) 54 210.500000 14315.2500 68.0059
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Total 388.250000 20927.5500 53.9023
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Number of Children (Unduplicated) With at Least One Service 60
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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 133 194.250000 8969.5500 0.0000
P 47 75.500000 3460.5000 3457.2500
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 0 0.000000 0.0000 0.0000
12 21.500000 1612.5000 0.0000
Other 52 97.000000 6885.0000 0.0000
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Total 244 388.250000 20927.5500 3457.2500