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:OTHER
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 38 55.500000 2064.6000 37.2000
Subtotal (Total Children Is Unduplicated) 38 55.500000 2064.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 11.000000 825.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 10.000000 555.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 25.500000 1912.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 27.500000 2062.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 26 31.000000 1720.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 49 114.500000 7788.0000 68.0175
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Total 170.000000 9852.6000 57.9565
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Number of Children (Unduplicated) With at Least One Service 53
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Center 09
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 0 0.000000 0.0000 0.0000
P 1 2.000000 150.0000 150.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 102 122.000000 6848.8500 0.0000
T 16 31.000000 2295.7500 2295.7500
8 15.000000 558.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 127 170.000000 9852.6000 2445.7500