CMS/EIP Fiscal Report Center: 52
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 25 114.500000 4194.3000 36.6314
Subtotal (Total Children Is Unduplicated) 25 114.500000 4194.3000 36.6314
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 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 4 8.000000 479.3600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 647.8400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 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 4 8.000000 647.8400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 24.000000 1438.0800 59.9200
Subtotal (Total Children Is Unduplicated) 19 60.000000 4184.8800 69.7480
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Total 174.500000 8379.1800 48.0182
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Number of Children (Unduplicated) With at Least One Service 25
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Center 52
Flag Claims Units Chgs Paid
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R 3 4.750000 264.2600 0.0000
U 0 0.000000 0.0000 0.0000
B 38 59.250000 2693.9800 0.0000
P 51 83.250000 4099.1200 4087.1600
D 0 0.000000 0.0000 0.0000
S 5 7.750000 288.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
9 19.500000 1033.5200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 106 174.500000 8379.1800 4087.1600