CMS/EIP Fiscal Report Center: 05
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 81 34.750000 1292.7000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 54 49.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 103 495.750000 18441.9000 37.2000
Subtotal (Total Children Is Unduplicated) 103 580.250000 19734.6000 34.0105
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 31.000000 2325.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 27.000000 2025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 23.500000 1304.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 23.500000 1304.2500 55.5000
Subtotal (Total Children Is Unduplicated) 55 154.000000 10526.2500 68.3523
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EI Services,Class #03
EPIC-99601-Early Steps Professional Development Fee 15 16.000000 240.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 46 55.000000 660.0000 12.0000
TRAV-TRAVS-Travel by mile 62 2082.000000 926.3700 0.4449
Subtotal (Total Children Is Unduplicated) 63 2153.000000 1826.3700 0.8483
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Total 2887.250000 32087.2200 11.1134
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Number of Children (Unduplicated) With at Least One Service 105
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Center 05
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 219 203.750000 7579.5000 3645.6000
P 244 2307.000000 12352.6200 12352.6200
D 1 1.000000 37.2000 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
491 374.250000 12071.4000 0.0000
Other 2 1.250000 46.5000 0.0000
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Total 957 2887.250000 32087.2200 15998.2200