CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/10/2023 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 76 281.750000 10397.4000 36.9029
Subtotal (Total Children Is Unduplicated) 76 281.750000 10397.4000 36.9029
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 26 41.000000 3075.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 25.500000 1912.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 17.500000 1312.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 41 66.000000 3663.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
Subtotal (Total Children Is Unduplicated) 66 168.000000 11205.7500 66.7009
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Total 449.750000 21603.1500 48.0337
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Number of Children (Unduplicated) With at Least One Service 78
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Center 53
Flag Claims Units Chgs Paid
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R 13 13.750000 738.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 60 67.250000 3307.2000 0.0000
P 296 313.750000 14361.1500 14361.1500
D 0 0.000000 0.0000 0.0000
S 2 2.250000 140.4000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
25 39.000000 2298.9000 0.0000
Other 13 13.750000 757.2000 0.0000
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Total 409 449.750000 21603.1500 14361.1500