CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 37 124.750000 4640.7000 37.2000
Subtotal (Total Children Is Unduplicated) 37 124.750000 4640.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 18.000000 999.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 10 21.500000 1261.5000 58.6744
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Total 146.250000 5902.2000 40.3569
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Number of Children (Unduplicated) With at Least One Service 39
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Center 03
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 85 112.250000 4555.0500 0.0000
P 8 9.500000 371.7000 371.7000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 1.500000 83.2500 0.0000
Other 15 23.000000 892.2000 0.0000
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Total 109 146.250000 5902.2000 371.7000