CMS/EIP Fiscal Report Center: 04
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 23 145.000000 5394.0000 37.2000
Subtotal (Total Children Is Unduplicated) 23 145.000000 5394.0000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 9.500000 712.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 3.500000 194.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 17.000000 943.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 9.000000 675.0000 75.0000
Subtotal (Total Children Is Unduplicated) 18 50.500000 3387.7500 67.0842
-----------------------------------------------------------------------------------------------------------------------
Total 195.500000 8781.7500 44.9194
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 26
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 54 94.250000 3908.5500 0.0000
P 34 56.250000 2270.5500 2270.5500
D 1 1.000000 75.0000 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
28 42.500000 2471.8500 0.0000
Other 1 1.500000 55.8000 0.0000
---------------------------------------------------------
Total 118 195.500000 8781.7500 2270.5500