CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2022 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 159 655.250000 24348.5500 37.1592
Subtotal (Total Children Is Unduplicated) 159 655.250000 24348.5500 37.1592
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 85.500000 4745.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 21.500000 1612.5000 75.0000
Subtotal (Total Children Is Unduplicated) 57 117.500000 7145.2500 60.8106
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Total 772.750000 31493.8000 40.7555
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Number of Children (Unduplicated) With at Least One Service 161
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Center 03
Flag Claims Units Chgs Paid
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R 4 6.000000 223.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 332 438.500000 17625.5000 0.0000
P 130 162.750000 7027.0000 6917.0000
D 5 7.250000 297.1500 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
95 124.500000 5029.0500 0.0000
Other 25 33.750000 1291.9000 0.0000
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Total 591 772.750000 31493.8000 6917.0000