CMS/EIP Fiscal Report Center: 10
Services beginning 04/01/2025 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 18 82.750000 3078.3000 37.2000
Subtotal (Total Children Is Unduplicated) 18 82.750000 3078.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.500000 688.3300 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 40.4900 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 9.500000 569.2400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 9.500000 769.3100 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 10.500000 850.2900 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.000000 719.0400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.000000 161.9600 80.9800
Subtotal (Total Children Is Unduplicated) 17 56.500000 4122.5800 72.9660
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Total 139.250000 7200.8800 51.7119
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Number of Children (Unduplicated) With at Least One Service 18
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Center 10
Flag Claims Units Chgs Paid
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R 8 8.500000 316.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 107 129.000000 6819.5800 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
1 1.750000 65.1000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 116 139.250000 7200.8800 0.0000