CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 27 14.250000 530.1000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 86 357.500000 13299.0000 37.2000
Subtotal (Total Children Is Unduplicated) 99 371.750000 13829.1000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 119.8600 59.9300
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 89.8800 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 675.5600 71.1116
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 271.4700 77.5629
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 230.9800 76.9933
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 12.500000 698.1700 55.8536
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 233.0500 58.2625
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.500000 799.4600 76.1390
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 363.2900 66.0527
Subtotal (Total Children Is Unduplicated) 24 63.000000 4263.5200 67.6749
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 3 3.500000 175.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 3.000000 150.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 3.000000 150.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 1 3.000000 150.0000 50.0000
INTR-T1013-INTERPRETER 22 40.500000 2075.0000 51.2346
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 182.000000 2184.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 7.000000 569.2400 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 8.000000 650.5600 81.3200
TRAV-TRAVS-Travel by mile 16 606.000000 265.8900 0.4388
Subtotal (Total Children Is Unduplicated) 39 860.000000 6569.6900 7.6392
-----------------------------------------------------------------------------------------------------------------------
Total 1294.750000 24662.3100 19.0479
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 117
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 295 886.750000 8410.0400 8410.0400
D 0 0.000000 0.0000 0.0000
S 1 0.750000 27.9000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 3.250000 126.8700 126.8700
493 404.000000 16097.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 791 1294.750000 24662.3100 8536.9100