CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 201 216.000000 8035.2000 37.2000
Subtotal (Total Children Is Unduplicated) 201 216.000000 8035.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.000000 1110.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
Subtotal (Total Children Is Unduplicated) 17 37.500000 2266.5000 60.4400
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 14.750000 737.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 10 12.000000 600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 9.500000 683.6200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 3.000000 215.8800 71.9600
Subtotal (Total Children Is Unduplicated) 23 40.250000 2308.9600 57.3655
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Total 293.750000 12610.6600 42.9299
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Number of Children (Unduplicated) With at Least One Service 220
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Center 02
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 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
0 0.000000 0.0000 0.0000
Other 405 293.750000 12610.6600 0.0000
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Total 405 293.750000 12610.6600 0.0000