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
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 615 2652.750000 98700.9000 37.2070
Subtotal (Total Children Is Unduplicated) 615 2652.750000 98700.9000 37.2070
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 42.000000 3150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 73 146.000000 10950.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 12 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 54.000000 2997.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 14.000000 785.8400 56.1314
Subtotal (Total Children Is Unduplicated) 116 296.000000 20687.8400 69.8914
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 32 242.000000 12104.0000 50.0165
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 19.000000 1367.2400 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 11 66.000000 4749.3600 71.9600
Subtotal (Total Children Is Unduplicated) 46 327.000000 18220.6000 55.7205
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Total 3275.750000 137609.3400 42.0085
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Number of Children (Unduplicated) With at Least One Service 619
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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 420 413.750000 19576.7000 18.6000
P 3031 2862.000000 118032.6400 118005.2000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3451 3275.750000 137609.3400 118023.8000