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
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 632 673.250000 25044.9000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1083 4324.500000 160871.4000 37.2000
Subtotal (Total Children Is Unduplicated) 1110 4997.750000 185916.3000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 15 12.000000 600.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.000000 161.9600 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 18.000000 1457.6400 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.500000 202.4500 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 7.500000 607.3500 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.500000 269.6400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 15 24.500000 1468.0400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 3.000000 242.9400 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 3 3.500000 283.4300 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 42.000000 3401.1600 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 85 105.500000 8543.3900 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 18.000000 1457.6400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 51 63.500000 5142.2300 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 72.500000 4344.2000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 133 208.500000 12493.3200 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 47.000000 3806.0600 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 77 117.500000 9515.1500 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 41 41.000000 5200.9500 126.8524
Subtotal (Total Children Is Unduplicated) 232 793.000000 59197.5500 74.6501
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Total 5790.750000 245113.8500 42.3285
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Number of Children (Unduplicated) With at Least One Service 1146
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Center 04
Flag Claims Units Chgs Paid
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R 50 75.250000 2799.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 945 1661.000000 65798.6000 0.0000
P 208 378.000000 14107.0400 14113.3000
D 15 28.750000 1069.5000 0.0000
S 4 10.250000 381.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2903 3637.500000 160958.1100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4125 5790.750000 245113.8500 14113.3000