CMS/EIP Fiscal Report Center: 54
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 88 480.000000 17846.7000 37.1806
Subtotal (Total Children Is Unduplicated) 88 480.000000 17846.7000 37.1806
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 40.500000 3037.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 14 27.000000 2025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 37 70.500000 3912.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 41.500000 3112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 78 234.000000 15931.5000 68.0833
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Total 714.000000 33778.2000 47.3084
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Number of Children (Unduplicated) With at Least One Service 90
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Center 54
Flag Claims Units Chgs Paid
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R 6 5.750000 213.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 62 81.500000 3595.8000 0.0000
P 430 553.750000 25327.2000 25327.2000
D 0 0.000000 0.0000 0.0000
S 1 1.500000 112.5000 0.0000
H 1 2.000000 111.0000 0.0000
T 0 0.000000 0.0000 0.0000
37 65.500000 4195.8000 0.0000
Other 2 4.000000 222.0000 0.0000
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Total 539 714.000000 33778.2000 25327.2000