CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 152 135.750000 5049.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 7.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 149 556.250000 20720.4000 37.2502
Subtotal (Total Children Is Unduplicated) 176 699.750000 25770.3000 36.8279
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.400000 705.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
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 12 22.740266 1705.5200 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.836800 662.7600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.927467 444.5600 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 34.000000 1887.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 9 18.000000 999.0000 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 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 46 124.904533 8197.8400 65.6328
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 36.0000 12.0000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
Subtotal (Total Children Is Unduplicated) 1 6.000000 251.8800 41.9800
-----------------------------------------------------------------------------------------------------------------------
Total 830.654533 34220.0200 41.1965
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 176
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 20 33.927467 2190.4400 2190.4400
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
756 796.727066 32029.5800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 776 830.654533 34220.0200 2190.4400