CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2025 ending 03/31/2025 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 47 40.250000 1497.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 72 444.500000 16535.4000 37.2000
Subtotal (Total Children Is Unduplicated) 72 484.750000 18032.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 40.4900 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 89.8800 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 18.500000 1498.1300 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 24 27.500000 2226.9500 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.000000 566.8600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 17.000000 1376.6600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 28.500000 1707.7200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 43 69.500000 4164.4400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 15.000000 1214.7000 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 39.500000 3198.7100 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 2001.9500 142.9964
Subtotal (Total Children Is Unduplicated) 66 244.500000 18540.7800 75.8314
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Total 729.250000 36573.4800 50.1522
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Number of Children (Unduplicated) With at Least One Service 75
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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 108 191.250000 8311.5000 0.0000
P 27 62.250000 2315.7000 2315.7000
D 3 3.500000 130.2000 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
357 472.250000 25816.0800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 495 729.250000 36573.4800 2315.7000