CMS/EIP Fiscal Report Center: 57
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 42 316.250000 11764.5000 37.2000
Subtotal (Total Children Is Unduplicated) 42 316.250000 11764.5000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 386.9600 77.3920
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 376.2200 57.8800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 13.500000 1021.4700 75.6644
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 15.500000 1192.4000 76.9290
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 14.000000 1085.8800 77.5629
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 395.9300 79.1860
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 42.500000 2416.2100 56.8520
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 286.3400 57.2680
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
Subtotal (Total Children Is Unduplicated) 39 112.500000 7591.8500 67.4831
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 1 5.000000 250.0000 50.0000
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Total 433.750000 19606.3500 45.2020
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Number of Children (Unduplicated) With at Least One Service 43
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Center 57
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 228 425.750000 19183.2200 19183.2200
T 0 0.000000 0.0000 0.0000
7 8.000000 423.1300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 235 433.750000 19606.3500 19183.2200