CMS/EIP Fiscal Report Center: 54
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 206 161.500000 6000.4000 37.1542
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 83 60.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 203 1334.250000 49549.7500 37.1368
Subtotal (Total Children Is Unduplicated) 356 1556.250000 55550.1500 35.6949
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 44 89.500000 6712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 16 31.000000 2325.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 48 94.500000 5244.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.000000 1275.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 43.500000 3262.5000 75.0000
Subtotal (Total Children Is Unduplicated) 102 341.500000 23282.2500 68.1764
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 2 1.750000 87.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.250000 12.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 0.500000 25.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 0.500000 25.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 1 0.500000 25.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 92 104.000000 0.0000 0.0000
INTR-T1013-INTERPRETER 1 2.000000 70.0000 35.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 109 187.000000 1870.0000 10.0000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 2 1.250000 46.2500 37.0000
TRAV-TRAVS-Travel by mile 53 770.000000 342.5100 0.4448
Subtotal (Total Children Is Unduplicated) 113 1068.750000 2553.7600 2.3895
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Total 2966.500000 81386.1600 27.4351
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Number of Children (Unduplicated) With at Least One Service 378
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Center 54
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 33 24.000000 891.4500 0.0000
S 1 0.250000 12.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 146 707.000000 7799.5300 7799.5300
2024 2232.500000 72580.4800 0.0000
Other 5 2.750000 102.2000 0.0000
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Total 2209 2966.500000 81386.1600 7799.5300