CMS/EIP Fiscal Report Center: 53
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 56 217.250000 8081.7000 37.2000
Subtotal (Total Children Is Unduplicated) 56 217.250000 8081.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 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 15 24.500000 1837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 19.000000 1425.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 20.000000 1500.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 30 46.500000 2580.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
SPCH-92610TL-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 48 127.000000 8565.4100 67.4442
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Total 344.250000 16647.1100 48.3576
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Number of Children (Unduplicated) With at Least One Service 57
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Center 53
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 33 36.000000 1890.5600 0.0000
P 207 236.000000 11149.3500 11149.3500
D 0 0.000000 0.0000 0.0000
S 23 31.750000 1237.8000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
25 30.000000 1677.6000 0.0000
Other 6 10.500000 691.8000 0.0000
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Total 294 344.250000 16647.1100 11149.3500