CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 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 981 3893.000000 144819.6000 37.2000
Subtotal (Total Children Is Unduplicated) 981 3893.000000 144819.6000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 3.000000 225.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 80 106.500000 8029.3600 75.3931
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 41 52.000000 3883.4300 74.6813
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 109 143.500000 7937.4800 55.3134
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 58 87.000000 6575.8300 75.5843
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 145 398.500000 27072.9600 67.9372
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.000000 350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 20.500000 1484.5400 72.4166
OCCT-97530HM-OT SESSION BY OT ASST 1 13.000000 748.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 243.9600 81.3200
Subtotal (Total Children Is Unduplicated) 7 43.500000 2827.3000 64.9954
-----------------------------------------------------------------------------------------------------------------------
Total 4335.000000 174719.8600 40.3045
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1001
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 613 1005.000000 41294.3500 0.0000
P 1979 3327.000000 133313.9100 130151.6300
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
---------------------------------------------------------
Total 2593 4335.000000 174719.8600 130151.6300