CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 Page: 1
List order: No List
Payclass Filters:OTHER
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 13 19.000000 706.8000 37.2000
Subtotal (Total Children Is Unduplicated) 13 19.000000 706.8000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 404.9000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 389.4800 59.9200
Subtotal (Total Children Is Unduplicated) 4 13.000000 915.8500 70.4500
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 9.000000 231.0000 25.6667
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 99.000000 5346.0000 54.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 4.000000 48.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 5.000000 406.6000 81.3200
Subtotal (Total Children Is Unduplicated) 16 117.000000 6031.6000 51.5521
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Total 149.000000 7654.2500 51.3708
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Number of Children (Unduplicated) With at Least One Service 33
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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 1 1.000000 54.0000 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
138 144.500000 7470.0500 0.0000
Other 6 3.500000 130.2000 0.0000
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Total 145 149.000000 7654.2500 0.0000