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:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 825 3112.500000 115785.0000 37.2000
Subtotal (Total Children Is Unduplicated) 825 3112.500000 115785.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 404.9000 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 15.500000 1255.1900 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 12 21.000000 1258.3200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 209.7200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 108.000000 8745.8400 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 79 132.000000 10657.7700 80.7407
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 9.000000 728.8200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 37 61.500000 4980.2700 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 283.4300 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 159 276.000000 16537.9200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.500000 689.0800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 566.8600 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
Subtotal (Total Children Is Unduplicated) 204 661.500000 46965.9600 70.9992
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Total 3774.000000 162750.9600 43.1243
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Number of Children (Unduplicated) With at Least One Service 825
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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 2338 3549.500000 153720.7100 153720.7100
T 0 0.000000 0.0000 0.0000
161 224.500000 9030.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2499 3774.000000 162750.9600 153720.7100