CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2025 ending 03/31/2025 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 42 258.750000 9625.5000 37.2000
Subtotal (Total Children Is Unduplicated) 42 258.750000 9625.5000 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 121.4700 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 40.4900 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 89.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.000000 728.8200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 16.500000 1336.1700 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 202.4500 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 10.500000 850.2900 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 16.000000 958.7200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 29 32.500000 1947.4000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.000000 485.8800 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 12.000000 971.7600 80.9800
Subtotal (Total Children Is Unduplicated) 41 108.500000 7733.3300 71.2749
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Total 367.250000 17358.8300 47.2671
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Number of Children (Unduplicated) With at Least One Service 45
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Center 04
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 108 191.250000 8311.5000 0.0000
P 27 62.250000 2315.7000 2315.7000
D 3 3.500000 130.2000 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
80 110.250000 6601.4300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 218 367.250000 17358.8300 2315.7000