CMS/EIP Fiscal Report Center: 06
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 39 190.500000 7086.6000 37.2000
Subtotal (Total Children Is Unduplicated) 39 190.500000 7086.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.500000 283.4300 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 2.000000 161.9600 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 80.9800 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 202.4500 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 14.500000 1093.4800 75.4124
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 16.500000 1279.3600 77.5370
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 11.000000 836.9600 76.0873
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 15.000000 1160.8800 77.3920
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 533.9700 76.2814
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.000000 422.1700 60.3100
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 9 12.500000 726.9000 58.1520
Subtotal (Total Children Is Unduplicated) 33 96.000000 7014.8800 73.0717
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Total 286.500000 14101.4800 49.2198
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Number of Children (Unduplicated) With at Least One Service 40
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Center 06
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
255 286.500000 14101.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 255 286.500000 14101.4800 0.0000