CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2025 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 12 20.250000 753.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 5 12.000000 446.4000 37.2000
Subtotal (Total Children Is Unduplicated) 12 32.250000 1199.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
Subtotal (Total Children Is Unduplicated) 2 6.000000 401.6400 66.9400
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EI Services,Class #03
EPIC-99601-Early Steps Professional Development Fee 1 8.000000 120.0000 15.0000
TRAV-TRAVS-Travel by mile 1 81.000000 36.0400 0.4449
Subtotal (Total Children Is Unduplicated) 1 89.000000 156.0400 1.7533
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Total 127.250000 1757.3800 13.8105
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Number of Children (Unduplicated) With at Least One Service 13
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Center 09
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 38 54.750000 1492.8200 1492.8200
D 8 69.000000 88.9200 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 1.000000 37.2000 37.2000
2 2.500000 138.4400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 50 127.250000 1757.3800 1530.0200