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
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 302 992.750000 36930.3000 37.2000
Subtotal (Total Children Is Unduplicated) 302 992.750000 36930.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 526.3700 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.000000 566.8600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
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 4 8.000000 479.3600 59.9200
SPCH-92522TLGT-EVAL OF SPCH SOUND PROD 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 20 39.500000 2923.1200 74.0030
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 11.000000 594.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 378.0000 54.0000
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 406.6000 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 7.000000 569.2400 81.3200
Subtotal (Total Children Is Unduplicated) 9 33.000000 2191.8000 66.4182
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Total 1065.250000 42045.2200 39.4698
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Number of Children (Unduplicated) With at Least One Service 310
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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 748 824.250000 32974.9800 32845.8400
T 0 0.000000 0.0000 0.0000
210 241.000000 9070.2400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 958 1065.250000 42045.2200 32845.8400