CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 1136 6317.750000 235020.3000 37.2000
Subtotal (Total Children Is Unduplicated) 1136 6317.750000 235020.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 26.000000 1982.8900 76.2650
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 68 90.000000 6791.8600 75.4651
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 43 55.000000 4190.7800 76.1960
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 20.000000 1121.0500 56.0525
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 86 114.500000 6416.6300 56.0404
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 17.000000 1283.9700 75.5276
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 78.500000 5917.4000 75.3809
OCTH-97165-OT EVAL LOW COMPLEXITY 4 5.000000 290.5500 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
Subtotal (Total Children Is Unduplicated) 151 416.000000 28679.3800 68.9408
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 22.000000 1160.0000 52.7273
OCCT-97530-OT SESSION BY LICENSED OT 8 41.000000 3151.6000 76.8683
OCCT-97530HM-OT SESSION BY OT ASST 1 16.000000 944.1600 59.0100
PHY-97110-PT SESSION BY LICENSED PT 4 16.000000 1301.1200 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 162.6400 81.3200
Subtotal (Total Children Is Unduplicated) 15 97.000000 6719.5200 69.2734
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Total 6830.750000 270419.2000 39.5885
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Number of Children (Unduplicated) With at Least One Service 1145
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Center 04
Flag Claims Units Chgs Paid
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R 77 103.500000 3850.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 1199 1890.250000 76281.0000 0.0000
P 3023 4837.000000 190288.0000 183318.5400
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 4299 6830.750000 270419.2000 183318.5400