CMS/EIP Fiscal Report Center: 55
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 118 113.750000 4231.5000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 6 7.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 122 521.250000 19390.5000 37.2000
Subtotal (Total Children Is Unduplicated) 146 642.250000 23622.0000 36.7801
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 635.8800 79.4850
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 311.9600 77.9900
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 590.3600 59.0360
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 44.000000 3383.7200 76.9027
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1235.8800 77.2425
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1085.8800 77.5629
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 42.000000 2357.5200 56.1314
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 230.8400 57.7100
Subtotal (Total Children Is Unduplicated) 50 150.000000 10432.0400 69.5469
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EI Services,Class #03
EPIC-99601-Early Steps Professional Development Fee 1 1.000000 15.0000 15.0000
TRAV-TRAVS-Travel by mile 1 70.000000 31.1500 0.4450
Subtotal (Total Children Is Unduplicated) 1 71.000000 46.1500 0.6500
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Total 863.250000 34100.1900 39.5021
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Number of Children (Unduplicated) With at Least One Service 146
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Center 55
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 40 147.000000 5586.5100 5586.5100
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 2 4.000000 323.9200 323.9200
724 712.250000 28189.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 766 863.250000 34100.1900 5910.4300