CMS/EIP Fiscal Report Center: 55
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 88 375.250000 13959.3000 37.2000
Subtotal (Total Children Is Unduplicated) 88 375.250000 13959.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 38.000000 2981.5600 78.4621
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 461.9600 76.9933
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 12.000000 923.9200 76.9933
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 12 24.000000 1402.7200 58.4467
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
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 58 120.000000 9179.4000 76.4950
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 14.000000 1109.8000 79.2714
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1223.9200 76.4950
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 473.9200 78.9867
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1061.9600 75.8543
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 311.9600 77.9900
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 76.000000 4279.8800 56.3142
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 461.6800 57.7100
Subtotal (Total Children Is Unduplicated) 87 344.000000 24304.4800 70.6526
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Total 719.250000 38263.7800 53.1996
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Number of Children (Unduplicated) With at Least One Service 91
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Center 55
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 89 167.750000 8171.0600 0.0000
P 235 441.500000 22333.0800 22267.5600
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
55 110.000000 7759.6400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 379 719.250000 38263.7800 22267.5600