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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 693 1542.500000 57381.0000 37.2000
Subtotal (Total Children Is Unduplicated) 693 1542.500000 57381.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 7.500000 416.2500 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 126.000000 6993.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.000000 750.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
Subtotal (Total Children Is Unduplicated) 80 151.000000 8603.5000 56.9768
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 30.000000 1500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 6 30.000000 1500.0000 50.0000
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Total 1723.500000 67484.5000 39.1555
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Number of Children (Unduplicated) With at Least One Service 697
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Center 03
Flag Claims Units Chgs Paid
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R 4 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 217 133.750000 5157.2000 0.0000
P 158 128.250000 5333.1500 5333.9900
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
1829 1410.750000 55005.6000 0.0000
Other 43 47.250000 1858.3500 0.0000
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Total 2252 1723.500000 67484.5000 5333.9900