CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 103 171.250000 6351.9000 37.0914
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 2.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 34 113.000000 4203.6000 37.2000
Subtotal (Total Children Is Unduplicated) 106 286.750000 10555.5000 36.8108
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 5.000000 375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 9.000000 675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.500000 416.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
Subtotal (Total Children Is Unduplicated) 13 30.500000 2112.0000 69.2459
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 9 6.250000 0.0000 0.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 17 22.000000 220.0000 10.0000
TRAV-TRAVS-Travel by mile 6 130.000000 57.8300 0.4448
Subtotal (Total Children Is Unduplicated) 18 158.250000 277.8300 1.7556
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Total 475.500000 12945.3300 27.2247
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Number of Children (Unduplicated) With at Least One Service 112
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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 1 0.500000 18.6000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 2.000000 20.0000 20.0000
493 473.000000 12906.7300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 496 475.500000 12945.3300 20.0000