CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 3 1.250000 46.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 34 79.500000 2957.4000 37.2000
Subtotal (Total Children Is Unduplicated) 37 80.750000 3003.9000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 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) 2 3.500000 262.5000 75.0000
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
INTR-T1013-INTERPRETER 16 26.250000 1312.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 8.000000 80.0000 10.0000
TRAV-TRAVS-Travel by mile 4 70.000000 29.4400 0.4206
Subtotal (Total Children Is Unduplicated) 22 104.250000 1421.9400 13.6397
-----------------------------------------------------------------------------------------------------------------------
Total 188.500000 4688.3400 24.8718
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 52
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 13 54.250000 639.8900 639.8900
D 2 29.000000 12.0500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 19 24.500000 1032.5000 1032.5000
118 80.750000 3003.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 152 188.500000 4688.3400 1672.3900