CMS/EIP Fiscal Report Center: 57
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 283 2088.000000 77594.5500 37.1621
Subtotal (Total Children Is Unduplicated) 283 2088.000000 77594.5500 37.1621
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 22.500000 1248.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 146 237.000000 17775.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 51 84.500000 6337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 65 98.500000 7387.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 228 388.500000 21561.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 36.000000 2700.0000 75.0000
Subtotal (Total Children Is Unduplicated) 269 889.000000 58660.5000 65.9848
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Total 2977.000000 136255.0500 45.7692
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Number of Children (Unduplicated) With at Least One Service 283
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Center 57
Flag Claims Units Chgs Paid
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R 6 11.750000 511.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 548 992.500000 46308.6000 0.0000
P 994 1931.500000 86781.0000 86219.4100
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 23 36.250000 2278.9500 1088.1500
3 5.000000 375.0000 375.0000
Other 0 0.000000 0.0000 0.0000
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Total 1574 2977.000000 136255.0500 87682.5600