CMS/EIP Fiscal Report Center: 52
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 44 165.750000 6165.9000 37.2000
Subtotal (Total Children Is Unduplicated) 44 165.750000 6165.9000 37.2000
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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-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 38.000000 2850.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 24.000000 1800.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 48.000000 2664.0000 55.5000
Subtotal (Total Children Is Unduplicated) 35 124.000000 8325.0000 67.1371
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Total 289.750000 14490.9000 50.0117
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Number of Children (Unduplicated) With at Least One Service 45
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Center 52
Flag Claims Units Chgs Paid
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R 2 1.000000 37.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 49 73.250000 3890.7000 0.0000
P 142 186.000000 8941.2000 8941.2000
D 0 0.000000 0.0000 0.0000
S 21 17.000000 820.2000 82.2000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7 12.500000 801.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 221 289.750000 14490.9000 9023.4000