CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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 27 13.750000 511.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 90 319.750000 11885.4000 37.1709
Subtotal (Total Children Is Unduplicated) 108 333.500000 12396.9000 37.1721
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.000000 455.9800 75.9967
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.500000 513.6000 68.4800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 13.000000 728.1300 56.0100
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 233.0500 58.2625
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.500000 799.4600 76.1390
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 317.9400 79.4850
Subtotal (Total Children Is Unduplicated) 18 51.000000 3498.1600 68.5914
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EI Services,Class #03
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
INTR-T1013-INTERPRETER 22 39.000000 1996.4000 51.1897
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 13.000000 156.0000 12.0000
TRAV-TRAVS-Travel by mile 17 460.000000 201.4100 0.4378
Subtotal (Total Children Is Unduplicated) 36 515.000000 2503.8100 4.8618
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Total 899.500000 18398.8700 20.4546
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Number of Children (Unduplicated) With at Least One Service 127
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Center 01
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 81 523.000000 3972.3300 3972.3300
D 1 14.000000 5.8300 0.0000
S 1 0.750000 27.9000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
432 361.750000 14392.8100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 515 899.500000 18398.8700 3972.3300