CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 49 21.500000 795.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 7.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 114 456.500000 16890.5000 37.0000
Subtotal (Total Children Is Unduplicated) 114 485.000000 17686.0000 36.4660
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 17.500000 1312.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 19.000000 1425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 32.500000 1803.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 13 20.500000 1137.7500 55.5000
Subtotal (Total Children Is Unduplicated) 40 120.000000 7908.0000 65.9000
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 0.500000 25.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.500000 75.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 27 53.000000 530.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 11 218.000000 96.9600 0.4448
Subtotal (Total Children Is Unduplicated) 28 282.000000 1198.4000 4.2496
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Total 887.000000 26792.4000 30.2056
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Number of Children (Unduplicated) With at Least One Service 114
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Center 05
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 197 194.250000 7187.2500 2747.2500
P 138 344.000000 8828.2700 8828.2700
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 0 0.000000 0.0000 0.0000
377 348.750000 10776.8800 278.1300
Other 0 0.000000 0.0000 0.0000
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Total 712 887.000000 26792.4000 11853.6500