CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 111 530.750000 19743.9000 37.2000
Subtotal (Total Children Is Unduplicated) 111 530.750000 19743.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 161.9600 107.9733
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 485.8800 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.500000 438.3500 58.4467
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 179.7600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 271.4700 77.5629
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 8.500000 664.4100 78.1659
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 39.000000 2228.5900 57.1433
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 15.500000 873.5100 56.3555
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 46.500000 3616.0700 77.7649
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 26.500000 2029.3600 76.5796
Subtotal (Total Children Is Unduplicated) 92 174.000000 12204.8000 70.1425
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Total 704.750000 31948.7000 45.3334
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Number of Children (Unduplicated) With at Least One Service 112
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Center 01
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 14 17.750000 1322.4100 0.0000
H 759 681.000000 30403.0900 30403.0900
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 14 6.000000 223.2000 0.0000
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Total 787 704.750000 31948.7000 30403.0900