CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 161 202.500000 7533.0000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 11 8.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 185 815.500000 30336.6000 37.2000
Subtotal (Total Children Is Unduplicated) 187 1026.000000 37869.6000 36.9099
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 140 278.999999 20925.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 20.000000 1500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 35.000000 2625.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 88 176.000000 9768.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
Subtotal (Total Children Is Unduplicated) 160 575.999999 39267.0000 68.1719
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 1 2.000000 81.9600 40.9800
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Total 1603.999999 77218.5600 48.1412
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Number of Children (Unduplicated) With at Least One Service 187
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Center 55
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 241 448.500000 23668.2000 0.0000
P 123 218.750000 11563.9000 11563.9000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 21 42.000000 3100.0000 0.0000
T 0 0.000000 0.0000 0.0000
946 894.749999 38886.4600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1331 1603.999999 77218.5600 11563.9000