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
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
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 286 1170.250000 43607.7000 37.2636
Subtotal (Total Children Is Unduplicated) 286 1170.250000 43607.7000 37.2636
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 36.000000 2915.2800 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 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1133.7200 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 2 4.000000 239.6800 59.9200
Subtotal (Total Children Is Unduplicated) 33 71.000000 5517.9200 77.7172
-----------------------------------------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------------------------------------
Total 1383.000000 58603.7300 42.3744
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 287
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1466 1383.000000 58603.7300 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
---------------------------------------------------------
Total 1466 1383.000000 58603.7300 0.0000