CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 545 392.250000 14591.7000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 577 2205.250000 82035.3000 37.2000
Subtotal (Total Children Is Unduplicated) 900 2597.500000 96627.0000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 2 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 242.9400 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 404.9000 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 121.4700 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 6 10.500000 629.1600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 20.000000 1619.6000 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 32.500000 2631.8500 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 404.9000 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 19.000000 1538.6200 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 41 75.000000 4494.0000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 179.7600 59.9200
Subtotal (Total Children Is Unduplicated) 55 185.500000 12940.5100 69.7602
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 4 4.000000 200.0000 50.0000
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Total 2787.000000 109767.5100 39.3855
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Number of Children (Unduplicated) With at Least One Service 904
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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 1 0.500000 18.6000 18.6000
T 0 0.000000 0.0000 0.0000
2629 2786.500000 109748.9100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2630 2787.000000 109767.5100 18.6000