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
Payclass Filters:GR
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 17 16.250000 604.5000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 4 4.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 15 65.000000 2418.0000 37.2000
Subtotal (Total Children Is Unduplicated) 19 85.500000 3022.5000 35.3509
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 359.5200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
Subtotal (Total Children Is Unduplicated) 6 18.000000 1289.1600 71.6200
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Total 103.500000 4311.6600 41.6586
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Number of Children (Unduplicated) With at Least One Service 19
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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 0 0.000000 0.0000 0.0000
P 1 2.000000 119.8400 119.8400
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 2 4.000000 323.9200 323.9200
99 97.500000 3867.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 102 103.500000 4311.6600 443.7600