CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 215 225.000000 8370.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 309 2213.500000 82342.2000 37.2000
Subtotal (Total Children Is Unduplicated) 309 2438.500000 90712.2000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.500000 430.4400 78.2618
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 4.500000 364.4100 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 40.4900 80.9800
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 2 2.500000 145.3800 58.1520
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 9.000000 530.4400 58.9378
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 2 2.500000 202.4500 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 55.500000 4431.6000 79.8486
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 109 127.500000 10133.5900 79.4791
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 25.500000 2023.1300 79.3384
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 88 98.500000 7853.9400 79.7354
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 48 64.500000 3836.1100 59.4746
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 218 340.500000 20104.4100 59.0438
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 74.000000 5923.7500 80.0507
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 142 235.000000 18671.5000 79.4532
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 76 76.000000 11946.7500 157.1941
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 316 1125.500000 86933.4600 77.2399
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 7.500000 609.9000 81.3200
Subtotal (Total Children Is Unduplicated) 1 7.500000 609.9000 81.3200
-----------------------------------------------------------------------------------------------------------------------
Total 3571.500000 178255.5600 49.9106
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 331
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 20.000000 744.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 333 546.500000 26223.1300 0.0000
P 534 969.250000 45858.0800 46320.9000
D 21 24.000000 1294.6900 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
1543 2007.750000 103942.7400 0.0000
Other 3 4.000000 192.9200 0.0000
---------------------------------------------------------
Total 2443 3571.500000 178255.5600 46320.9000