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
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 992 7087.750000 263664.3000 37.2000
Subtotal (Total Children Is Unduplicated) 992 7087.750000 263664.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 18.500000 1477.2000 79.8486
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.000000 545.9300 77.9900
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 24 40.000000 3218.2700 80.4568
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 554.9000 79.2714
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 13.000000 1022.8400 78.6800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 39 68.000000 4061.4300 59.7269
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 12.500000 733.5300 58.6824
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 47 76.500000 5806.2700 75.8990
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 88.000000 6716.6100 76.3251
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 14.000000 1067.9400 76.2814
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 34.000000 2639.7000 77.6382
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 100 162.000000 9158.9600 56.5368
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 25.500000 1421.8800 55.7600
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.500000 1171.4700 75.5787
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
Subtotal (Total Children Is Unduplicated) 189 595.500000 40655.9000 68.2719
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Total 7683.250000 304320.2000 39.6083
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Number of Children (Unduplicated) With at Least One Service 992
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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 5626 7631.750000 302404.4000 301223.3000
T 0 0.000000 0.0000 0.0000
28 51.500000 1915.8000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5654 7683.250000 304320.2000 301223.3000