CMS/EIP Fiscal Report Center: 57
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 88 552.750000 20562.3000 37.2000
Subtotal (Total Children Is Unduplicated) 88 552.750000 20562.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 39 65.000000 4875.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 26.500000 1987.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 16 23.500000 1762.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 64 108.000000 5994.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 72 237.500000 15667.5000 65.9684
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 7.000000 350.0000 50.0000
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Total 797.250000 36579.8000 45.8825
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Number of Children (Unduplicated) With at Least One Service 88
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Center 57
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 280 522.000000 22966.0500 83.2500
P 137 262.750000 12946.9500 12468.1500
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 2 4.000000 261.0000 112.2000
2 7.000000 350.0000 350.0000
Other 1 1.500000 55.8000 0.0000
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Total 422 797.250000 36579.8000 13013.6000