CMS/EIP Fiscal Report Center: 52
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 111 496.750000 18393.6500 37.0280
Subtotal (Total Children Is Unduplicated) 111 496.750000 18393.6500 37.0280
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 74 147.000000 11025.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 55.500000 4162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 49.000000 3675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 80 158.500000 8796.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
Subtotal (Total Children Is Unduplicated) 94 426.500000 28750.5000 67.4103
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Total 923.250000 47144.1500 51.0633
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Number of Children (Unduplicated) With at Least One Service 111
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Center 52
Flag Claims Units Chgs Paid
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R 2 4.250000 233.7000 0.0000
U 0 0.000000 0.0000 0.0000
B 112 151.250000 7636.3000 74.4000
P 469 650.250000 32917.0000 32806.7100
D 2 3.500000 205.8000 0.0000
S 60 53.500000 2364.1500 204.9000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
37 60.500000 3787.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 682 923.250000 47144.1500 33086.0100