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
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 5 8.250000 306.9000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 30 73.000000 2715.6000 37.2000
Subtotal (Total Children Is Unduplicated) 34 81.250000 3022.5000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 23.500000 1359.7500 57.8617
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 24 45.000000 2933.2500 65.1833
-----------------------------------------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------------------------------------
Total 268.750000 6198.6600 23.0648
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 50
-----------------------------------------------------------------------------------------------------------------------
Center 03
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 4 140.000000 85.4100 85.4100
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
91 128.750000 6113.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 95 268.750000 6198.6600 85.4100