CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 36 22.500000 836.8500 37.1933
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 17 12.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 124 674.750000 25006.9000 37.0610
Subtotal (Total Children Is Unduplicated) 124 709.500000 25843.7500 36.4253
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 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 6 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 18.500000 1387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 5.500000 412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 27 52.000000 3900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.500000 750.0000 71.4286
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 19 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 21.000000 1165.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 52 98.000000 5439.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 12.500000 937.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 49.000000 3675.0000 75.0000
Subtotal (Total Children Is Unduplicated) 104 344.000000 23178.7500 67.3801
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 20 22.250000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 25 35.000000 350.0000 10.0000
TRAV-TRAVS-Travel by mile 13 221.000000 98.3100 0.4448
Subtotal (Total Children Is Unduplicated) 26 278.250000 448.3100 1.6112
-----------------------------------------------------------------------------------------------------------------------
Total 1331.750000 49470.8100 37.1472
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 124
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 9.000000 542.7000 0.0000
U 0 0.000000 0.0000 0.0000
B 94 130.500000 6358.0500 37.2000
P 387 462.250000 20450.3000 20441.7000
D 17 23.000000 1250.7000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 16 78.000000 860.1300 860.1300
414 623.750000 19757.6800 0.0000
Other 4 5.250000 251.2500 138.7500
---------------------------------------------------------
Total 939 1331.750000 49470.8100 21477.7800