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
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 58 49.750000 1850.7000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 58 365.750000 13605.9000 37.2000
Subtotal (Total Children Is Unduplicated) 90 415.500000 15456.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 10.500000 787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.000000 375.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 20.000000 1110.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 15 44.500000 2918.2500 65.5787
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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 1 10.000000 500.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 2 15.000000 225.0000 15.0000
Subtotal (Total Children Is Unduplicated) 2 26.000000 775.0000 29.8077
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Total 486.000000 19149.8500 39.4030
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Number of Children (Unduplicated) With at Least One Service 91
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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 0 0.000000 0.0000 0.0000
T 26 26.000000 775.0000 775.0000
325 460.000000 18374.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 351 486.000000 19149.8500 775.0000