CMS/EIP Fiscal Report Center: 04
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 51 300.500000 11178.6000 37.2000
Subtotal (Total Children Is Unduplicated) 51 300.500000 11178.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 14 16.500000 1237.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 12.000000 905.9800 75.4983
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 27 32.000000 1787.0500 55.8453
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 25.500000 1924.4600 75.4690
Subtotal (Total Children Is Unduplicated) 40 99.500000 6818.7400 68.5301
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Total 400.000000 17997.3400 44.9934
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Number of Children (Unduplicated) With at Least One Service 55
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Center 04
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 42 68.000000 3108.1800 0.0000
P 138 282.000000 11380.0500 11370.0500
D 1 1.000000 75.0000 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
41 49.000000 3434.1100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 222 400.000000 17997.3400 11370.0500