CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2025 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 290 942.750000 35070.3000 37.2000
Subtotal (Total Children Is Unduplicated) 290 942.750000 35070.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 242.9400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 242.9400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 179.7600 59.9200
Subtotal (Total Children Is Unduplicated) 3 11.500000 847.0300 73.6548
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 5.000000 270.0000 54.0000
Subtotal (Total Children Is Unduplicated) 2 5.000000 270.0000 54.0000
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Total 959.250000 36187.3300 37.7246
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Number of Children (Unduplicated) With at Least One Service 290
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Center 04
Flag Claims Units Chgs Paid
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R 37 52.500000 1953.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 454 728.250000 27353.5800 0.0000
P 103 178.500000 6880.7500 6880.7500
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 594 959.250000 36187.3300 6880.7500