CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1047 4192.250000 155951.7000 37.2000
Subtotal (Total Children Is Unduplicated) 1047 4192.250000 155951.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 61 85.500000 6412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 47 67.000000 5025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 104 148.000000 8214.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 71.000000 5325.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 128 376.500000 25298.6600 67.1943
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 7 21.500000 1547.1400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 6.500000 374.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 2 5.500000 395.7800 71.9600
Subtotal (Total Children Is Unduplicated) 9 33.500000 2317.3200 69.1737
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Total 4602.250000 183567.6800 39.8865
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Number of Children (Unduplicated) With at Least One Service 1062
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Center 04
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 425 726.500000 29611.2000 0.0000
P 2308 3875.750000 153956.4800 150647.7200
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2733 4602.250000 183567.6800 150647.7200