CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 1030 5845.750000 217461.9000 37.2000
Subtotal (Total Children Is Unduplicated) 1030 5845.750000 217461.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 11.500000 910.3400 79.1600
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 27 32.000000 2561.4600 80.0456
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.500000 202.4500 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 12 14.000000 1112.7900 79.4850
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 7.000000 412.8100 58.9729
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 32 38.500000 2267.1400 58.8868
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 4 4.500000 364.4100 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 34.500000 2632.3500 76.3000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 77 102.000000 7742.6900 75.9087
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 50 65.000000 4970.6800 76.4720
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 30.500000 1734.7400 56.8767
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 104 142.000000 7998.1300 56.3249
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 25.000000 1904.9000 76.1960
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 60 83.500000 6316.3200 75.6446
Subtotal (Total Children Is Unduplicated) 213 597.500000 41515.1800 69.4815
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Total 6443.250000 258977.0800 40.1935
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Number of Children (Unduplicated) With at Least One Service 1044
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Center 04
Flag Claims Units Chgs Paid
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R 36 57.750000 2148.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 1047 1727.000000 69057.1400 0.0000
P 2450 4307.000000 166462.5700 166032.1700
D 51 75.500000 3318.7200 0.0000
S 1 2.500000 93.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
205 272.500000 17860.1500 0.0000
Other 1 1.000000 37.2000 0.0000
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Total 3791 6443.250000 258977.0800 166032.1700