CMS/EIP Fiscal Report Center: 09
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 43 120.250000 4473.3000 37.2000
Subtotal (Total Children Is Unduplicated) 43 120.250000 4473.3000 37.2000
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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 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 32.500000 2437.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 31 55.000000 4125.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 39 68.500000 3831.0000 55.9270
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 15.500000 1162.5000 75.0000
Subtotal (Total Children Is Unduplicated) 55 196.000000 13325.2500 67.9860
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Total 316.250000 17798.5500 56.2800
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Number of Children (Unduplicated) With at Least One Service 60
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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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 117 185.750000 8823.4500 8823.4500
T 0 0.000000 0.0000 0.0000
41 71.500000 4969.3500 0.0000
Other 33 59.000000 4005.7500 0.0000
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Total 191 316.250000 17798.5500 8823.4500