CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 70 28.250000 1050.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 23 22.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 61 276.000000 10267.2000 37.2000
Subtotal (Total Children Is Unduplicated) 91 326.500000 11318.1000 34.6649
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.000000 225.0000 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 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 23.500000 1762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 11.000000 825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.500000 412.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 16.500000 1237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 29.500000 1637.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 32.500000 1803.7500 55.5000
Subtotal (Total Children Is Unduplicated) 54 132.000000 8622.7500 65.3239
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 17 27.000000 270.0000 10.0000
TRAV-TRAVS-Travel by mile 21 678.000000 301.6700 0.4449
Subtotal (Total Children Is Unduplicated) 23 705.000000 571.6700 0.8109
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Total 1163.500000 20512.5200 17.6300
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Number of Children (Unduplicated) With at Least One Service 95
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Center 05
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 135 837.000000 9194.4200 9194.4200
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
440 326.500000 11318.1000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 575 1163.500000 20512.5200 9194.4200