CMS/EIP Fiscal Report Center: 52
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
CASE-CASE-NON-TCM CASE MANAGEMENT 13 8.750000 316.2000 36.1371
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 1.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 27 117.250000 4361.7000 37.2000
Subtotal (Total Children Is Unduplicated) 36 127.500000 4677.9000 36.6894
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Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 461.6800 57.7100
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 18.000000 1016.6800 56.4822
Subtotal (Total Children Is Unduplicated) 13 34.000000 2051.3200 60.3329
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 12 7.500000 0.0000 0.0000
EPIC-99601-Early Steps Professional Development Fee 1 1.000000 15.0000 15.0000
TRAV-TRAVS-Travel by mile 3 40.000000 17.8000 0.4450
Subtotal (Total Children Is Unduplicated) 15 48.500000 32.8000 0.6763
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Total 210.000000 6762.0200 32.2001
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Number of Children (Unduplicated) With at Least One Service 40
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Center 52
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 1 2.750000 102.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 7 47.000000 494.7600 464.9600
135 160.250000 6164.9600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 143 210.000000 6762.0200 464.9600