CMS/EIP Fiscal Report Center: 10
Services beginning 07/01/2024 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 91 382.000000 14210.4000 37.2000
Subtotal (Total Children Is Unduplicated) 91 382.000000 14210.4000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.000000 635.8800 79.4850
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 320.7200 58.3127
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.500000 1096.4700 75.6186
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 461.9600 76.9933
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.000000 672.6300 61.1482
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.500000 649.4600 76.4071
Subtotal (Total Children Is Unduplicated) 18 62.000000 4498.5400 72.5571
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 89.000000 1068.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 13.500000 1018.2600 75.4267
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.250000 96.9700 77.5760
Subtotal (Total Children Is Unduplicated) 1 103.750000 2183.2300 21.0432
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Total 547.750000 20892.1700 38.1418
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Number of Children (Unduplicated) With at Least One Service 95
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Center 10
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 118 103.750000 2183.2300 2183.2300
D 1 0.500000 18.6000 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
397 443.500000 18690.3400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 516 547.750000 20892.1700 2183.2300