CMS/EIP Fiscal Report Center: 10
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
TCM-T1017TL-TARGETED CASE MANAGEMENT 112 387.750000 14424.3000 37.2000
Subtotal (Total Children Is Unduplicated) 112 387.750000 14424.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.000000 1125.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.500000 749.2500 59.9400
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.500000 412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 14 47.500000 3335.2500 70.2158
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 39.000000 468.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 8.500000 611.6600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 35.9800 71.9600
Subtotal (Total Children Is Unduplicated) 1 48.000000 1115.6400 23.2425
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Total 483.250000 18875.1900 39.0589
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Number of Children (Unduplicated) With at Least One Service 114
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Center 10
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 57 48.000000 1115.6400 1115.6400
D 1 0.500000 18.6000 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
400 434.750000 17740.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 458 483.250000 18875.1900 1115.6400