CMS/EIP Fiscal Report Center: 54
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 111 584.500000 21743.4000 37.2000
Subtotal (Total Children Is Unduplicated) 111 584.500000 21743.4000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 36.500000 2737.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 29 52.500000 3937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.500000 487.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 23 39.500000 2962.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 45 84.000000 4662.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.500000 862.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 22.000000 1650.0000 75.0000
Subtotal (Total Children Is Unduplicated) 86 278.500000 19044.7500 68.3833
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 100.0000 50.0000
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Total 865.000000 40888.1500 47.2695
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Number of Children (Unduplicated) With at Least One Service 112
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Center 54
Flag Claims Units Chgs Paid
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R 1 1.000000 37.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 97 116.250000 5720.7000 0.0000
P 512 624.250000 27679.6000 27558.4000
D 3 6.000000 450.0000 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
59 105.000000 6422.2500 0.0000
Other 11 12.500000 578.4000 559.8000
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Total 683 865.000000 40888.1500 28118.2000