CMS/EIP Fiscal Report Center: 52
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 26 102.000000 3785.1000 37.1088
Subtotal (Total Children Is Unduplicated) 26 102.000000 3785.1000 37.1088
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 30.000000 1665.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 20 82.000000 5526.0000 67.3902
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 3.000000 150.0000 50.0000
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Total 187.000000 9461.1000 50.5941
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Number of Children (Unduplicated) With at Least One Service 26
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Center 52
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 32 44.000000 2199.6000 65.1000
P 73 108.250000 5515.2000 5515.2000
D 0 0.000000 0.0000 0.0000
S 28 26.750000 1146.3000 30.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4 8.000000 600.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 137 187.000000 9461.1000 5610.3000