CMS/EIP Fiscal Report Center: 55
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 134 100.750000 3747.9000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 3.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 152 546.750000 20339.1000 37.2000
Subtotal (Total Children Is Unduplicated) 184 650.500000 24087.0000 37.0284
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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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 34.000000 2550.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 15.902133 1192.6600 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 6 11.902133 892.6600 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 40.000000 2220.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
Subtotal (Total Children Is Unduplicated) 44 125.804266 8499.3200 67.5599
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EI Services,Class #03
EPIC-99601-Early Steps Professional Development Fee 1 1.000000 15.0000 15.0000
TRAV-TRAVS-Travel by mile 1 70.000000 31.1500 0.4450
Subtotal (Total Children Is Unduplicated) 1 71.000000 46.1500 0.6500
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Total 847.304266 32632.4700 38.5133
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Number of Children (Unduplicated) With at Least One Service 184
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Center 55
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 39 144.804266 5269.4700 5269.4700
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
763 702.500000 27363.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 802 847.304266 32632.4700 5269.4700