CMS/EIP Fiscal Report Center: 55
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 296 1207.500000 44993.4000 37.2616
Subtotal (Total Children Is Unduplicated) 296 1207.500000 44993.4000 37.2616
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 38.000000 3077.2400 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 647.8400 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 299.6000 59.9200
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 13 26.000000 2105.4800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 359.5200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
Subtotal (Total Children Is Unduplicated) 40 91.000000 7011.1600 77.0457
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 75.000000 4050.0000 54.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 6.000000 487.9200 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 9 60.750000 4940.1900 81.3200
Subtotal (Total Children Is Unduplicated) 18 141.750000 9478.1100 66.8650
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Total 1440.250000 61482.6700 42.6889
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Number of Children (Unduplicated) With at Least One Service 297
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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 1494 1440.250000 61482.6700 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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1494 1440.250000 61482.6700 0.0000