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
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 36 39.000000 1450.8000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 98 217.750000 8016.6000 36.8156
Subtotal (Total Children Is Unduplicated) 116 256.750000 9467.4000 36.8740
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 329.5600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 25.500000 2064.9900 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 36.000000 2915.2800 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 58.000000 3475.3600 59.9200
Subtotal (Total Children Is Unduplicated) 54 127.000000 8947.1500 70.4500
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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
TRAV-TRAVS-Travel by mile 1 167.000000 74.2900 0.4449
Subtotal (Total Children Is Unduplicated) 7 186.500000 826.2900 4.4305
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Total 570.250000 19240.8400 33.7411
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Number of Children (Unduplicated) With at Least One Service 138
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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 55 239.000000 4919.7900 4919.7900
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
285 331.250000 14321.0500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 340 570.250000 19240.8400 4919.7900