CMS/EIP Fiscal Report Center: 57
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 3.750000 139.5000 37.2000
Subtotal (Total Children Is Unduplicated) 1 4.000000 148.8000 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
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 16.000000 1211.9600 75.7475
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 29.500000 2212.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.500000 412.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 48.000000 2672.8400 55.6842
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
Subtotal (Total Children Is Unduplicated) 36 112.000000 7406.8000 66.1321
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Total 116.000000 7555.6000 65.1345
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Number of Children (Unduplicated) With at Least One Service 36
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Center 57
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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 51 79.000000 5292.5500 5292.5500
T 2 3.500000 194.2500 194.2500
22 33.500000 2068.8000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 75 116.000000 7555.6000 5486.8000