CMS/EIP Fiscal Report Center: 57
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 42 36.250000 1348.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 104 3712.250000 138095.7000 37.2000
Subtotal (Total Children Is Unduplicated) 107 3748.500000 139444.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 445.3900 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.000000 599.2000 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 30.000000 2429.4000 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 48.000000 3887.0400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 202.4500 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 50.500000 4089.4900 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 86 135.500000 8119.1600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.500000 149.8000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
Subtotal (Total Children Is Unduplicated) 95 292.000000 20529.2800 70.3058
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Total 4040.500000 159973.4800 39.5925
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Number of Children (Unduplicated) With at Least One Service 108
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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 335 592.000000 29930.9200 29930.9200
T 4 7.000000 440.5000 440.5000
267 3441.500000 129602.0600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 606 4040.500000 159973.4800 30371.4200