CMS/EIP Fiscal Report Center: 07
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 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 356 739.000000 27500.1000 37.2126
Subtotal (Total Children Is Unduplicated) 356 739.000000 27500.1000 37.2126
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 359.5200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 485.8800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 485.8800 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 809.8000 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.000000 1198.4000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
Subtotal (Total Children Is Unduplicated) 20 68.000000 4874.8400 71.6888
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Total 807.000000 32374.9400 40.1176
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Number of Children (Unduplicated) With at Least One Service 358
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Center 07
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 117 79.250000 3081.1000 0.0000
P 937 726.750000 29256.6400 29232.7200
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 4 1.000000 37.2000 0.0000
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Total 1058 807.000000 32374.9400 29232.7200