CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 59 221.750000 8249.1000 37.2000
Subtotal (Total Children Is Unduplicated) 59 221.750000 8249.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 959.8000 79.9833
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 479.3600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 74.000000 5932.7200 80.1719
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 18.000000 1457.6400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 809.8000 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 28.000000 2267.4400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 44.000000 2609.9600 59.3173
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 479.3600 59.9200
Subtotal (Total Children Is Unduplicated) 53 208.000000 15481.9600 74.4325
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Total 429.750000 23731.0600 55.2206
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Number of Children (Unduplicated) With at Least One Service 64
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Center 55
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 71 117.000000 5660.4800 0.0000
P 126 234.750000 12217.4600 12053.6600
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
39 78.000000 5853.1200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 236 429.750000 23731.0600 12053.6600