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:OTHER
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 1 3.000000 111.6000 37.2000
Subtotal (Total Children Is Unduplicated) 1 3.000000 111.6000 37.2000
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EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
Subtotal (Total Children Is Unduplicated) 1 1.000000 81.3200 81.3200
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Total 4.000000 192.9200 48.2300
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Number of Children (Unduplicated) With at Least One Service 2
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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 1 1.000000 81.3200 81.3200
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
1 3.000000 111.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2 4.000000 192.9200 81.3200