CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:OTHER
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 29 62.000000 2306.4000 37.2000
Subtotal (Total Children Is Unduplicated) 29 62.000000 2306.4000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
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 2 3.500000 283.4300 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 242.9400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
Subtotal (Total Children Is Unduplicated) 4 14.500000 1047.8500 72.2655
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 5.000000 135.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 68.000000 3672.0000 54.0000
Subtotal (Total Children Is Unduplicated) 20 73.000000 3807.0000 52.1507
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Total 149.500000 7161.2500 47.9013
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Number of Children (Unduplicated) With at Least One Service 52
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Center 57
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 0 0.000000 0.0000 0.0000
D 1 1.000000 54.0000 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
88 97.000000 5191.4500 0.0000
Other 41 51.500000 1915.8000 0.0000
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Total 130 149.500000 7161.2500 0.0000