CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 44 236.250000 8788.5000 37.2000
Subtotal (Total Children Is Unduplicated) 44 236.250000 8788.5000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 30.000000 2250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 50.000000 2775.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 18.500000 1387.5000 75.0000
Subtotal (Total Children Is Unduplicated) 40 105.000000 6841.5000 65.1571
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Total 341.250000 15630.0000 45.8022
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Number of Children (Unduplicated) With at Least One Service 47
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Center 04
Flag Claims Units Chgs Paid
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R 7 10.000000 596.4000 0.0000
U 0 0.000000 0.0000 0.0000
B 113 175.500000 7238.4000 0.0000
P 55 84.500000 3648.9000 3647.6000
D 9 13.250000 492.9000 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
44 58.000000 3653.4000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 228 341.250000 15630.0000 3647.6000