CMS/EIP Fiscal Report Center: 05
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 115 46.500000 1729.8000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 65 51.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 79 316.250000 11764.5000 37.2000
Subtotal (Total Children Is Unduplicated) 135 414.500000 13494.3000 32.5556
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 23.000000 1725.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 8.500000 562.5000 66.1765
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 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 16.500000 1237.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 17.500000 949.0500 54.2314
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 24 38.500000 2136.7500 55.5000
Subtotal (Total Children Is Unduplicated) 42 126.000000 8153.5500 64.7107
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 15.000000 750.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 22 47.000000 705.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 34 39.000000 468.0000 12.0000
TRAV-TRAVS-Travel by mile 66 1634.000000 726.9200 0.4449
Subtotal (Total Children Is Unduplicated) 70 1739.000000 2849.9200 1.6388
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Total 2279.500000 24497.7700 10.7470
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Number of Children (Unduplicated) With at Least One Service 138
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Center 05
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 280 1865.000000 11003.4700 11003.4700
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 0 0.000000 0.0000 0.0000
610 414.500000 13494.3000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 890 2279.500000 24497.7700 11003.4700