CMS/EIP Fiscal Report Center: 55
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 152 135.750000 5049.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 8 7.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 166 832.500000 30996.9000 37.2335
Subtotal (Total Children Is Unduplicated) 178 976.000000 36046.8000 36.9332
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 24.000000 1800.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
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 99 199.000000 14925.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 20.000000 1500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 24.000000 1800.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 58 115.000000 6382.5000 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 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 144 474.000000 32488.5000 68.5411
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 36.0000 12.0000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
Subtotal (Total Children Is Unduplicated) 1 6.000000 251.8800 41.9800
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Total 1456.000000 68787.1800 47.2439
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Number of Children (Unduplicated) With at Least One Service 178
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Center 55
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 172 317.250000 16518.6000 0.0000
P 109 202.927467 10469.8400 9628.3400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 15 30.000000 2250.0000 0.0000
T 0 0.000000 0.0000 0.0000
814 905.822533 39548.7400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1110 1456.000000 68787.1800 9628.3400