CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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 33 32.250000 1199.7000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 144 407.500000 15159.0000 37.2000
Subtotal (Total Children Is Unduplicated) 151 439.750000 16358.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 58.500000 4126.1400 70.5323
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 35.000000 2625.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 415.0000 69.1667
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 49.000000 2719.5000 55.5000
Subtotal (Total Children Is Unduplicated) 58 148.500000 9885.6400 66.5700
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EI Services,Class #03
INTR-T1013-INTERPRETER 3 5.750000 402.5000 70.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 5.000000 60.0000 12.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
TRAV-TRAVS-Travel by mile 1 12.000000 5.3400 0.4450
Subtotal (Total Children Is Unduplicated) 5 24.750000 611.7600 24.7176
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Total 613.000000 26856.1000 43.8109
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Number of Children (Unduplicated) With at Least One Service 153
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Center 03
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 74 135.250000 8388.4000 8388.4000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 108 119.750000 4784.1000 4784.1000
295 358.000000 13683.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 477 613.000000 26856.1000 13172.5000