CMS/EIP Fiscal Report Center: 53
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 90 176.750000 6556.5000 37.0948
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 6.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 37 123.250000 4584.9000 37.2000
Subtotal (Total Children Is Unduplicated) 98 306.750000 11141.4000 36.3208
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Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 1.500000 75.0000 50.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 12.000000 900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 16.000000 888.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 17 49.000000 3228.0000 65.8776
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 11 12.500000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12 16.000000 160.0000 10.0000
TRAV-TRAVS-Travel by mile 5 153.000000 68.0700 0.4449
Subtotal (Total Children Is Unduplicated) 12 181.500000 228.0700 1.2566
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Total 537.250000 14597.4700 27.1707
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Number of Children (Unduplicated) With at Least One Service 99
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Center 53
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 0 0.000000 0.0000 0.0000
S 6 4.500000 224.1000 0.0000
H 0 0.000000 0.0000 0.0000
T 6 138.000000 90.0700 90.0700
541 393.250000 14170.8000 0.0000
Other 1 1.500000 112.5000 0.0000
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Total 554 537.250000 14597.4700 90.0700