CMS/EIP Fiscal Report Center: 05
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 484 1354.500000 50387.4000 37.2000
Subtotal (Total Children Is Unduplicated) 484 1354.500000 50387.4000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH 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-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 9 12.000000 829.2300 69.1025
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 30 62.000000 3100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 5.000000 250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 44.500000 3202.2200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 57.9200 14.4800
Subtotal (Total Children Is Unduplicated) 41 116.500000 6682.1000 57.3571
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Total 1483.000000 57898.7300 39.0416
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Number of Children (Unduplicated) With at Least One Service 491
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Center 05
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 2288 1354.500000 50387.4000 48055.5000
P 127 128.500000 7511.3300 7511.3300
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 2415 1483.000000 57898.7300 55566.8300