CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 80.9800 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 3.000000 242.9400 80.9800
Subtotal (Total Children Is Unduplicated) 4 8.000000 553.6800 69.2100
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 325.2800 81.3200
Subtotal (Total Children Is Unduplicated) 2 5.000000 406.6000 81.3200
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Total 13.000000 960.2800 73.8677
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Number of Children (Unduplicated) With at Least One Service 5
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Center 01
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 4 4.000000 325.2800 325.2800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 6.000000 465.1600 0.0000
T 1 2.000000 119.8400 119.8400
1 1.000000 50.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11 13.000000 960.2800 445.1200