CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2025 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 255 886.250000 32968.5000 37.2000
Subtotal (Total Children Is Unduplicated) 255 886.250000 32968.5000 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 121.4700 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 6.000000 485.8800 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 149.8000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 12.000000 719.0400 59.9200
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 3 3.000000 242.9400 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 242.9400 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.000000 728.8200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 364.4100 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.000000 119.8400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 10.000000 599.2000 59.9200
Subtotal (Total Children Is Unduplicated) 23 60.500000 4341.2000 71.7554
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Total 946.750000 37309.7000 39.4082
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Number of Children (Unduplicated) With at Least One Service 257
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Center 04
Flag Claims Units Chgs Paid
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R 26 40.500000 1506.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 386 656.750000 24693.7800 0.0000
P 96 169.500000 6461.9500 6461.9500
D 3 3.500000 130.2000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
53 75.500000 4479.9700 0.0000
Other 1 1.000000 37.2000 0.0000
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Total 565 946.750000 37309.7000 6461.9500