CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 878 3451.750000 128405.1000 37.2000
Subtotal (Total Children Is Unduplicated) 878 3451.750000 128405.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 404.9000 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 12.000000 971.7600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 13.500000 851.0400 63.0400
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 84.000000 6802.3200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.500000 1255.1900 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 77.000000 6235.4600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 9.500000 769.3100 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 46.000000 3725.0800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 12.000000 971.7600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 115 195.000000 11684.4000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 27.500000 1647.8000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 283.4300 80.9800
Subtotal (Total Children Is Unduplicated) 158 504.500000 35926.3700 71.2118
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Total 3956.250000 164331.4700 41.5372
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Number of Children (Unduplicated) With at Least One Service 878
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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 2743 3956.250000 164331.4700 164312.8700
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2743 3956.250000 164331.4700 164312.8700