CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 83 189.750000 7077.3000 37.2980
Subtotal (Total Children Is Unduplicated) 83 189.750000 7077.3000 37.2980
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 20 35.500000 2662.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 31 37.000000 2775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 53 76.500000 4245.7500 55.5000
Subtotal (Total Children Is Unduplicated) 68 189.000000 12293.2500 65.0437
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 5.750000 0.0000 0.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 7.000000 350.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 4 18.750000 781.7600 41.6939
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Total 397.500000 20152.3100 50.6976
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Number of Children (Unduplicated) With at Least One Service 91
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Center 09
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 25 22.750000 1003.7600 1003.7600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 196 274.500000 15419.2500 0.0000
T 0 0.000000 0.0000 0.0000
59 100.250000 3729.3000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 280 397.500000 20152.3100 1003.7600