CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 5 8.250000 306.9000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 71 198.750000 7393.5000 37.2000
Subtotal (Total Children Is Unduplicated) 75 207.000000 7700.4000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 20.500000 1537.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.000000 975.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 395.6900 56.5271
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 43.000000 2442.0000 56.7907
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 43 91.500000 5881.9400 64.2835
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EI Services,Class #03
INTR-T1013-INTERPRETER 1 2.500000 157.5000 63.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 2.000000 24.0000 12.0000
TRAV-TRAVS-Travel by mile 1 138.000000 61.4100 0.4450
Subtotal (Total Children Is Unduplicated) 2 142.500000 242.9100 1.7046
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Total 441.000000 13825.2500 31.3498
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Number of Children (Unduplicated) With at Least One Service 84
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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 6 143.000000 310.4100 310.4100
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
202 298.000000 13514.8400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 208 441.000000 13825.2500 310.4100