CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
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 1227 2997.750000 111507.0000 37.1969
Subtotal (Total Children Is Unduplicated) 1227 2997.750000 111507.0000 37.1969
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 179.7600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 11 19.500000 1363.0800 69.9015
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 29 72.000000 3888.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 3.000000 243.9600 81.3200
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
Subtotal (Total Children Is Unduplicated) 31 78.000000 4375.9200 56.1015
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Total 3095.250000 117246.0000 37.8793
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Number of Children (Unduplicated) With at Least One Service 1239
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Center 01
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 1 1.000000 54.0000 54.0000
D 76 77.500000 4350.5400 0.0000
S 895 672.500000 25017.0000 0.0000
H 3272 2333.750000 87400.2600 87400.2600
T 0 0.000000 0.0000 0.0000
5 3.250000 154.5000 0.0000
Other 16 7.250000 269.7000 0.0000
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Total 4265 3095.250000 117246.0000 87454.2600