CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 43 64.000000 2380.8000 37.2000
Subtotal (Total Children Is Unduplicated) 43 64.000000 2380.8000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 21.000000 1575.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 23 36.500000 2737.5000 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 19 32.000000 2400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 19.500000 1082.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 38 61.000000 3385.5000 55.5000
Subtotal (Total Children Is Unduplicated) 62 176.500000 11638.5000 65.9405
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EI Services,Class #03
TRAV-TRAVS-Travel by mile 1 52.000000 22.8700 0.4398
Subtotal (Total Children Is Unduplicated) 1 52.000000 22.8700 0.4398
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Total 292.500000 14042.1700 48.0074
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Number of Children (Unduplicated) With at Least One Service 63
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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 26 100.500000 3280.1200 3280.1200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 129 192.000000 10762.0500 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 155 292.500000 14042.1700 3280.1200