CMS/EIP Fiscal Report Center: 54
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 92 481.000000 17893.2000 37.2000
Subtotal (Total Children Is Unduplicated) 92 481.000000 17893.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 18.000000 1007.8400 55.9911
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.600000 1095.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 19.600000 1470.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 13 24.500000 1837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 19.500000 1091.0900 55.9533
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 36 68.000000 3780.6300 55.5975
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 30.000000 2250.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
Subtotal (Total Children Is Unduplicated) 65 235.700000 15644.5600 66.3749
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Total 716.700000 33537.7600 46.7947
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Number of Children (Unduplicated) With at Least One Service 93
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Center 54
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 514 613.600000 27194.7000 27145.9500
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
52 100.000000 6110.5600 0.0000
Other 2 3.100000 232.5000 71.2500
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Total 568 716.700000 33537.7600 27217.2000