CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 58 54.250000 2018.1000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 92 539.250000 20060.1000 37.2000
Subtotal (Total Children Is Unduplicated) 92 593.500000 22078.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 10.500000 787.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 26 32.000000 2400.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 20 24.500000 1861.4200 75.9763
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 6.500000 360.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 48 75.000000 4195.6500 55.9420
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 11.500000 862.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 62.500000 4738.3300 75.8133
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 3384.5000 178.1316
Subtotal (Total Children Is Unduplicated) 72 255.000000 19544.6500 76.6457
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Total 848.500000 41622.8500 49.0546
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Number of Children (Unduplicated) With at Least One Service 95
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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 42 68.000000 3108.1800 0.0000
P 153 299.500000 13849.5100 14563.7700
D 1 1.000000 75.0000 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
363 480.000000 24590.1600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 559 848.500000 41622.8500 14563.7700