CMS/EIP Fiscal Report Center: 05
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 73 32.000000 1190.4000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 24 23.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 68 288.000000 10705.9500 37.1734
Subtotal (Total Children Is Unduplicated) 95 343.500000 11896.3500 34.6328
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 19.000000 1425.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 21.000000 1575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 21.000000 1575.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 26.500000 1470.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 22 31.000000 1720.5000 55.5000
Subtotal (Total Children Is Unduplicated) 51 142.500000 9459.0000 66.3789
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 0.250000 12.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 24 36.000000 360.0000 10.0000
TRAV-TRAVS-Travel by mile 25 840.000000 373.3300 0.4444
Subtotal (Total Children Is Unduplicated) 26 877.250000 795.8300 0.9072
-----------------------------------------------------------------------------------------------------------------------
Total 1363.250000 22151.1800 16.2488
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 97
-----------------------------------------------------------------------------------------------------------------------
Center 05
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 164 964.750000 10091.1900 10091.1900
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
452 398.500000 12059.9900 163.6400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 616 1363.250000 22151.1800 10254.8300