CMS/EIP Fiscal Report Center: 06
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
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 336 983.500000 36623.4000 37.2378
Subtotal (Total Children Is Unduplicated) 336 983.500000 36623.4000 37.2378
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 89.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.000000 242.9400 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 5.500000 445.3900 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.000000 566.8600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 4.500000 364.4100 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.000000 242.9400 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 3.500000 283.4300 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 239.6800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 5.500000 329.5600 59.9200
Subtotal (Total Children Is Unduplicated) 18 39.000000 2926.5600 75.0400
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 2 15.000000 1219.8000 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 9.000000 731.8800 81.3200
Subtotal (Total Children Is Unduplicated) 3 24.000000 1951.6800 81.3200
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Total 1046.500000 41501.6400 39.6576
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Number of Children (Unduplicated) With at Least One Service 336
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Center 06
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 0 0.000000 0.0000 0.0000
1595 1046.500000 41501.6400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1595 1046.500000 41501.6400 0.0000