CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 49 135.500000 5040.6000 37.2000
Subtotal (Total Children Is Unduplicated) 49 135.500000 5040.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 13 24.000000 1400.2500 58.3438
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Total 159.500000 6440.8500 40.3815
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Number of Children (Unduplicated) With at Least One Service 50
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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 7 11.500000 464.4000 0.0000
P 14 17.250000 714.9000 714.9000
D 1 0.500000 18.6000 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
94 122.500000 4954.6500 0.0000
Other 4 7.750000 288.3000 0.0000
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Total 120 159.500000 6440.8500 714.9000