CMS/EIP Fiscal Report Center: 57
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 60 375.000000 13950.0000 37.2000
Subtotal (Total Children Is Unduplicated) 60 375.000000 13950.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 36.000000 2700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 30.500000 2287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 65.500000 3635.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.000000 525.0000 75.0000
Subtotal (Total Children Is Unduplicated) 56 160.000000 10557.0000 65.9813
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Total 535.000000 24507.0000 45.8075
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Number of Children (Unduplicated) With at Least One Service 63
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Center 57
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 205 374.000000 17862.3000 0.0000
P 5 6.000000 411.0000 411.0000
D 0 0.000000 0.0000 0.0000
S 2 3.500000 233.2500 0.0000
H 20 37.750000 1404.3000 1404.3000
T 0 0.000000 0.0000 0.0000
59 113.750000 4596.1500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 291 535.000000 24507.0000 1815.3000