CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2022 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 151 196.000000 7288.2000 37.1847
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 226 862.250000 32043.6000 37.1628
Subtotal (Total Children Is Unduplicated) 284 1060.000000 39331.8000 37.1055
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 81.500000 6112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 54.000000 4050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 32.000000 2400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 111 197.000000 10933.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 32.000000 2400.0000 75.0000
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 193 432.500000 28203.5000 65.2104
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EI Services,Class #03
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 2.000000 100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 11.000000 110.0000 10.0000
TRAV-TRAVS-Travel by mile 2 134.000000 59.6100 0.4449
Subtotal (Total Children Is Unduplicated) 4 156.000000 719.6100 4.6129
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Total 1648.500000 68254.9100 41.4043
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Number of Children (Unduplicated) With at Least One Service 321
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Center 03
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 132 318.000000 13210.3300 13210.3300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 23.500000 660.0300 660.0300
T 0 0.000000 0.0000 0.0000
1162 1307.000000 54384.5500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1301 1648.500000 68254.9100 13870.3600