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
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 36 22.500000 836.8500 37.1933
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 17 12.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 41 179.250000 6662.6500 37.1696
Subtotal (Total Children Is Unduplicated) 72 214.000000 7499.5000 35.0444
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 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 12 24.000000 1332.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 18 61.000000 4029.0000 66.0492
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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
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Total 553.250000 11976.8100 21.6481
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Number of Children (Unduplicated) With at Least One Service 78
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Center 54
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 3 4.250000 157.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 14 74.000000 599.1300 599.1300
326 475.000000 11220.1800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 343 553.250000 11976.8100 599.1300