CMS/EIP Fiscal Report Center: 54
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 31 25.000000 930.0000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 6.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 64 316.000000 11755.2000 37.2000
Subtotal (Total Children Is Unduplicated) 85 347.500000 12685.2000 36.5042
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Screening, Eval, and Assessment,Class #02
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 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-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 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 2 4.000000 300.0000 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 7 13.500000 1012.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 15 30.000000 1665.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.500000 1462.5000 75.0000
Subtotal (Total Children Is Unduplicated) 39 104.000000 7098.0000 68.2500
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EI Services,Class #03
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 1 0.500000 25.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.500000 25.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 20 15.500000 0.0000 0.0000
EPIC-99601-Early Steps Professional Development Fee 21 26.000000 390.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 5.000000 60.0000 12.0000
TRAV-TRAVS-Travel by mile 9 91.000000 40.4900 0.4449
Subtotal (Total Children Is Unduplicated) 26 138.500000 540.4900 3.9025
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Total 590.000000 20323.6900 34.4469
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Number of Children (Unduplicated) With at Least One Service 93
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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 13 23.250000 1185.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 32 122.500000 2285.4300 2285.4300
390 443.500000 16825.3600 0.0000
Other 1 0.750000 27.9000 0.0000
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Total 436 590.000000 20323.6900 2285.4300