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:TPIN
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 1 0.250000 9.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 3.750000 139.5000 37.2000
Subtotal (Total Children Is Unduplicated) 1 4.000000 148.8000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 12.000000 962.7900 80.2325
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 13.000000 772.3300 59.4100
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.000000 923.9200 76.9933
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 20.500000 1552.4500 75.7293
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 236.9600 78.9867
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 155.9800 77.9900
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 80.9800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 34.500000 1950.1100 56.5249
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.000000 235.2600 58.8150
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 34 105.000000 7104.7500 67.6643
-----------------------------------------------------------------------------------------------------------------------
Total 109.000000 7253.5500 66.5463
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 34
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 47 70.000000 4765.6200 4765.6500
T 3 5.500000 322.9300 322.9300
21 33.500000 2165.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 71 109.000000 7253.5500 5088.5800