CMS/EIP Fiscal Report Center: 54
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 94 583.000000 21678.3000 37.1840
Subtotal (Total Children Is Unduplicated) 94 583.000000 21678.3000 37.1840
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 809.8000 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 8.000000 611.9600 76.4950
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 7.000000 530.9800 75.8543
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 359.5200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 38.000000 2215.0800 58.2916
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 485.8800 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 421.4700 76.6309
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 19.100000 1480.3400 77.5047
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 20.000000 1571.7600 78.5880
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 19.100000 1453.4300 76.0958
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 959.8000 79.9833
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 20.500000 1573.3800 76.7502
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.500000 1193.0000 58.1951
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 42 81.000000 4670.0900 57.6554
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 24.000000 1883.7200 78.4883
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.000000 1331.8100 78.3418
Subtotal (Total Children Is Unduplicated) 86 321.700000 22199.8600 69.0080
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EI Services,Class #03
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 2 3.000000 215.8800 71.9600
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Total 907.700000 44094.0400 48.5778
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Number of Children (Unduplicated) With at Least One Service 94
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Center 54
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 73 88.000000 4152.5200 3168.3000
P 560 669.000000 30503.0700 30503.0700
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
68 131.000000 8371.7300 0.0000
Other 16 19.700000 1066.7200 71.2500
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Total 717 907.700000 44094.0400 33742.6200