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
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 873 3536.750000 131567.1000 37.2000
Subtotal (Total Children Is Unduplicated) 873 3536.750000 131567.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 34.500000 2593.4800 75.1733
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 109 147.000000 11066.8600 75.2848
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 5.500000 412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 59 77.000000 5767.4000 74.9013
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 32.000000 1776.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 139 191.000000 10567.1000 55.3251
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 36.000000 2700.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 89 133.000000 10025.8300 75.3822
Subtotal (Total Children Is Unduplicated) 229 678.500000 46391.9200 68.3742
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Total 4215.250000 177959.0200 42.2179
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Number of Children (Unduplicated) With at Least One Service 890
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Center 04
Flag Claims Units Chgs Paid
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R 1 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 557 924.750000 37730.4700 0.0000
P 1667 2895.750000 115151.7500 114819.5600
D 25 42.750000 2066.9700 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.500000 55.8000 0.0000
256 347.500000 22842.4300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2507 4215.250000 177959.0200 114819.5600