CMS/EIP Fiscal Report Center: 55
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 113 90.250000 3357.3000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 21 23.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 163 904.250000 33628.8000 37.1897
Subtotal (Total Children Is Unduplicated) 171 1018.250000 36986.1000 36.3232
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 971.7600 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 599.2000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 226.000000 18301.4800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 34.000000 2753.3200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 42.000000 3401.1600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 647.8400 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 64.000000 5182.7200 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 76.000000 4553.9200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 34.000000 2037.2800 59.9200
Subtotal (Total Children Is Unduplicated) 140 516.000000 39216.3600 76.0007
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Total 1534.250000 76202.4600 49.6676
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Number of Children (Unduplicated) With at Least One Service 171
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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 226 490.750000 25349.3000 0.0000
P 37 74.000000 5655.5600 5655.5600
D 1 1.500000 55.8000 0.0000
S 0 0.000000 0.0000 0.0000
H 22 44.000000 3563.1200 0.0000
T 8 16.000000 1295.6800 1295.6800
757 908.000000 40283.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1051 1534.250000 76202.4600 6951.2400