CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 Page: 1
List order: No List
Payclass Filters:GR
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 105 160.250000 5929.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 6.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 33 83.750000 3098.7500 37.0000
Subtotal (Total Children Is Unduplicated) 111 250.000000 9028.0000 36.1120
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 8.500000 637.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 11.500000 638.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 14 30.500000 2034.0000 66.6885
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 4 4.750000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 7 8.000000 80.0000 10.0000
TRAV-TRAVS-Travel by mile 2 88.000000 39.1600 0.4450
Subtotal (Total Children Is Unduplicated) 7 100.750000 119.1600 1.1827
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Total 381.250000 11181.1600 29.3276
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Number of Children (Unduplicated) With at Least One Service 112
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Center 53
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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 57 26.000000 962.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5 91.500000 142.4100 142.4100
409 262.250000 10021.2500 0.0000
Other 1 1.500000 55.5000 0.0000
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Total 472 381.250000 11181.1600 142.4100