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
Agency Filter:EIP DEI DEIP
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 652 647.750000 24096.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1233 4997.500000 185907.0000 37.2000
Subtotal (Total Children Is Unduplicated) 1264 5645.250000 210003.3000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 12 10.750000 537.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 13 18.500000 1387.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 48.500000 3643.4800 75.1233
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 144 198.500000 14938.3300 75.2561
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 12.000000 900.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 87 116.000000 8716.3200 75.1407
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 41.000000 2275.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 191 350.500000 19445.8700 55.4804
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 57.000000 4275.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 145 253.500000 19076.6600 75.2531
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 59 59.000000 7023.6500 119.0449
Subtotal (Total Children Is Unduplicated) 332 1196.750000 84172.8100 70.3345
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Total 6842.000000 294176.1100 42.9956
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Number of Children (Unduplicated) With at Least One Service 1291
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Center 04
Flag Claims Units Chgs Paid
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R 1 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 557 924.750000 37730.4700 0.0000
P 1699 2938.750000 119997.6900 122204.7800
D 25 42.750000 2066.9700 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.500000 55.8000 0.0000
2444 2931.250000 134213.5800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4727 6842.000000 294176.1100 122204.7800