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
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 548 507.000000 18851.1000 37.1817
TCM-T1017TL-TARGETED CASE MANAGEMENT 569 2306.250000 86294.7000 37.4178
Subtotal (Total Children Is Unduplicated) 911 2813.250000 105145.8000 37.3752
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 2 7.000000 350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 388.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 18.000000 1350.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 24.500000 1837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 14.000000 1050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 52.000000 2886.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 373.5000 67.9091
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 47 156.000000 10169.7500 65.1907
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 7 9.000000 450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 7 10.000000 500.0000 50.0000
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Total 2979.250000 115815.5500 38.8741
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Number of Children (Unduplicated) With at Least One Service 916
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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 4 3.000000 111.6000 111.6000
T 0 0.000000 0.0000 0.0000
2913 2976.250000 115703.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2917 2979.250000 115815.5500 111.6000