CMS/EIP Fiscal Report Center: 03
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: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 44 125.750000 4677.9000 37.2000
Subtotal (Total Children Is Unduplicated) 44 125.750000 4677.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 15.000000 832.5000 55.5000
Subtotal (Total Children Is Unduplicated) 10 16.500000 915.7500 55.5000
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Total 142.250000 5593.6500 39.3227
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Number of Children (Unduplicated) With at Least One Service 46
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Center 03
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
94 142.250000 5593.6500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 94 142.250000 5593.6500 0.0000