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:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 7 20.000000 744.0000 37.2000
Subtotal (Total Children Is Unduplicated) 7 20.000000 744.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 364.4100 80.9800
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.000000 359.5200 59.9200
Subtotal (Total Children Is Unduplicated) 6 18.000000 1247.0400 69.2800
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.000000 432.0000 54.0000
Subtotal (Total Children Is Unduplicated) 1 8.000000 432.0000 54.0000
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Total 46.000000 2423.0400 52.6748
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Number of Children (Unduplicated) With at Least One Service 9
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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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 21 29.000000 1356.9900 1356.9900
T 0 0.000000 0.0000 0.0000
11 12.500000 764.8200 0.0000
Other 3 4.500000 301.2300 0.0000
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Total 35 46.000000 2423.0400 1356.9900