CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 685 715.250000 26607.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 490 2194.750000 81506.2000 37.1369
Subtotal (Total Children Is Unduplicated) 954 2910.000000 108113.5000 37.1524
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 6 5.250000 262.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 12.000000 900.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 38 56.000000 4200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 34 47.000000 3525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 19.000000 1054.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 79 116.000000 6438.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 13.500000 1012.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 50.000000 3750.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 2 2.000000 152.3000 76.1500
Subtotal (Total Children Is Unduplicated) 122 349.750000 23226.0500 66.4076
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Total 3259.750000 131339.5500 40.2913
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Number of Children (Unduplicated) With at Least One Service 959
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Center 04
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 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
2562 3259.750000 131339.5500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2562 3259.750000 131339.5500 0.0000