CMS/EIP Fiscal Report Center: 57
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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 58 50.000000 1860.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 118 790.000000 29388.0000 37.2000
Subtotal (Total Children Is Unduplicated) 118 840.000000 31248.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 46.500000 3499.4600 75.2572
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 56.000000 4200.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 29.500000 2212.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 83 127.000000 7057.3400 55.5696
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 9.000000 675.0000 75.0000
Subtotal (Total Children Is Unduplicated) 99 296.000000 19471.3000 65.7814
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 15.000000 750.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 2 15.000000 225.0000 15.0000
Subtotal (Total Children Is Unduplicated) 2 31.000000 1025.0000 33.0645
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Total 1167.000000 51744.3000 44.3396
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Number of Children (Unduplicated) With at Least One Service 119
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Center 57
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 361 637.500000 29998.1500 29998.1500
T 28 29.500000 969.2500 969.2500
353 500.000000 20776.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 742 1167.000000 51744.3000 30967.4000