CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 36 39.000000 1450.8000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 141 383.000000 14163.9000 36.9815
Subtotal (Total Children Is Unduplicated) 151 422.000000 15614.7000 37.0017
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.500000 449.4000 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 49.000000 3905.1600 79.6971
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 70.000000 5540.5600 79.1509
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 272.7200 68.1800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 72.500000 4344.2000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
Subtotal (Total Children Is Unduplicated) 76 210.000000 15057.8400 71.7040
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EI Services,Class #03
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 0.500000 25.0000 50.0000
INTR-T1013-INTERPRETER 4 8.000000 595.0000 74.3750
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 11.000000 132.0000 12.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
TRAV-TRAVS-Travel by mile 1 167.000000 74.2900 0.4449
Subtotal (Total Children Is Unduplicated) 7 187.500000 907.6100 4.8406
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Total 819.500000 31580.1500 38.5359
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Number of Children (Unduplicated) With at Least One Service 165
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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 88 300.000000 9619.1700 9619.1700
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
423 519.500000 21960.9800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 511 819.500000 31580.1500 9619.1700