CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 99 100.000000 3720.0000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 8.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 111 454.000000 16879.5000 37.1795
Subtotal (Total Children Is Unduplicated) 128 562.750000 20599.5000 36.6051
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 2105.4800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 26.000000 2105.4800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 42.000000 2516.6400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 359.5200 59.9200
Subtotal (Total Children Is Unduplicated) 40 104.000000 7411.0400 71.2600
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Total 666.750000 28010.5400 42.0106
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Number of Children (Unduplicated) With at Least One Service 128
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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 0 0.000000 0.0000 0.0000
P 20 40.000000 3070.7200 3070.7200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 119.8400 0.0000
T 0 0.000000 0.0000 0.0000
610 624.750000 24819.9800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 631 666.750000 28010.5400 3070.7200