CMS/EIP Fiscal Report Center: 09
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 54 161.500000 6007.8000 37.2000
Subtotal (Total Children Is Unduplicated) 54 161.500000 6007.8000 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 24 42.500000 3187.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 30.500000 2287.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 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 38 67.000000 3718.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 15.000000 1125.0000 75.0000
Subtotal (Total Children Is Unduplicated) 50 187.000000 12679.5000 67.8048
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Total 348.500000 18687.3000 53.6221
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Number of Children (Unduplicated) With at Least One Service 59
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Center 09
Flag Claims Units Chgs Paid
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R 10 13.250000 492.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 151 239.250000 11199.1500 0.0000
P 0 0.000000 0.0000 0.0000
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
17 33.000000 2475.0000 0.0000
Other 34 63.000000 4520.2500 0.0000
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Total 212 348.500000 18687.3000 0.0000