CMS/EIP Fiscal Report Center: 54
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 85 447.750000 16637.7000 37.1585
Subtotal (Total Children Is Unduplicated) 85 447.750000 16637.7000 37.1585
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.000000 599.2000 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 445.3900 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 647.8400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 21.000000 1660.0900 79.0519
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 27.500000 2226.9500 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 18.000000 1457.6400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 31.000000 1857.5200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 27 53.000000 3175.7600 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.000000 1376.6600 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 13.500000 1093.2300 80.9800
Subtotal (Total Children Is Unduplicated) 69 216.500000 15512.0400 71.6491
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Total 664.250000 32149.7400 48.4001
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Number of Children (Unduplicated) With at Least One Service 86
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Center 54
Flag Claims Units Chgs Paid
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R 13 14.750000 617.6600 0.0000
U 0 0.000000 0.0000 0.0000
B 165 219.500000 10386.2500 0.0000
P 244 303.500000 13958.7800 13850.8800
D 0 0.000000 0.0000 0.0000
S 23 27.500000 1023.0000 0.0000
H 3 5.000000 231.4400 0.0000
T 3 3.000000 199.1600 0.0000
39 74.500000 4811.5300 0.0000
Other 14 16.500000 921.9200 0.0000
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Total 504 664.250000 32149.7400 13850.8800