CMS/EIP Fiscal Report Center: 05
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 558 1573.000000 58515.6000 37.2000
Subtotal (Total Children Is Unduplicated) 558 1573.000000 58515.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 329.5600 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 7 12.500000 831.4300 66.5144
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 27.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 16.000000 864.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 15.000000 1219.8000 81.3200
PHY-97110-PT SESSION BY LICENSED PT 2 4.000000 325.2800 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
Subtotal (Total Children Is Unduplicated) 16 37.000000 2517.4000 68.0378
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Total 1622.500000 61864.4300 38.1291
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Number of Children (Unduplicated) With at Least One Service 559
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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 2454 1379.250000 51308.1000 38327.6600
P 37 39.500000 2745.9900 2745.9900
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
98 68.750000 2788.3400 602.8400
Other 190 135.000000 5022.0000 0.0000
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Total 2779 1622.500000 61864.4300 41676.4900