CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:MED
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 147 543.000000 20199.6000 37.2000
Subtotal (Total Children Is Unduplicated) 147 543.000000 20199.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 8.500000 667.4000 78.5176
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.000000 375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.000000 635.8800 79.4850
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 9.000000 683.9700 75.9967
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 39.000000 2202.0700 56.4633
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 17.000000 950.1300 55.8900
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 36.500000 2785.3400 76.3107
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 28.500000 2164.4100 75.9442
Subtotal (Total Children Is Unduplicated) 87 165.500000 11423.3300 69.0231
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Total 708.500000 31622.9300 44.6336
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Number of Children (Unduplicated) With at Least One Service 149
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Center 01
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 1 1.500000 83.2500 0.0000
S 1 1.000000 75.0000 0.0000
H 787 698.500000 31185.6800 31185.6800
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 13 7.500000 279.0000 0.0000
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Total 802 708.500000 31622.9300 31185.6800