CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 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 280 533.750000 19739.5000 36.9827
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 7.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 106 426.750000 15789.7500 37.0000
Subtotal (Total Children Is Unduplicated) 297 967.500000 35529.2500 36.7227
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 225.0000 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 11 18.000000 1350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 17 26.500000 1987.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 32.000000 1776.0000 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 5 7.500000 562.5000 75.0000
Subtotal (Total Children Is Unduplicated) 43 100.500000 6845.2500 68.1119
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EI Services,Class #03
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 0.250000 12.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 2.750000 137.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 0.250000 12.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 6 7.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10 12.000000 120.0000 10.0000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 3 1.750000 64.7500 37.0000
TRAV-TRAVS-Travel by mile 3 136.000000 60.5200 0.4450
Subtotal (Total Children Is Unduplicated) 14 161.250000 457.7700 2.8389
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Total 1229.250000 42832.2700 34.8442
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Number of Children (Unduplicated) With at Least One Service 298
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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 2 0.750000 27.7500 0.0000
D 10 12.750000 471.7500 0.0000
S 88 39.500000 1461.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 14 149.250000 630.7700 630.7700
1511 1014.250000 39635.7500 0.0000
Other 10 9.250000 342.2500 0.0000
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Total 1635 1225.750000 42569.7700 630.7700