CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 12 6.250000 231.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 3.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 35 179.750000 6576.7500 36.5883
Subtotal (Total Children Is Unduplicated) 35 189.250000 6808.0000 35.9736
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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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 48.000000 3600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 18.000000 1180.0000 65.5556
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 42.000000 2331.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 31 153.000000 10369.0000 67.7712
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 1.000000 0.0000 0.0000
TRAV-TRAVS-Travel by mile 20 311.000000 138.3300 0.4448
Subtotal (Total Children Is Unduplicated) 20 312.000000 138.3300 0.4434
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Total 654.250000 17315.3300 26.4659
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Number of Children (Unduplicated) With at Least One Service 35
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Center 52
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 13 18.750000 1110.7500 0.0000
P 66 107.500000 5054.5000 5002.1500
D 6 12.000000 666.0000 0.0000
S 4 4.500000 166.5000 0.0000
H 4 8.000000 600.0000 37.5000
T 29 324.000000 1113.3300 1013.3300
135 179.500000 8604.2500 520.0000
Other 0 0.000000 0.0000 0.0000
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Total 257 654.250000 17315.3300 6572.9800