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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1331 3356.750000 124861.8000 37.1972
Subtotal (Total Children Is Unduplicated) 1331 3356.750000 124861.8000 37.1972
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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 3 6.000000 485.5600 80.9267
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 6.000000 359.5200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 202.4500 80.9800
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) 16 27.000000 1906.9300 70.6270
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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 3461.750000 131144.6500 37.8839
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Number of Children (Unduplicated) With at Least One Service 1343
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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 77 79.500000 4512.1800 0.0000
S 979 746.750000 27779.1000 0.0000
H 3623 2614.250000 98012.4700 98012.4700
T 0 0.000000 0.0000 0.0000
5 3.250000 154.5000 0.0000
Other 27 17.000000 632.4000 0.0000
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Total 4712 3461.750000 131144.6500 98066.4700