CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2025 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 70 60.500000 2250.6000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 93 514.500000 19139.4000 37.2000
Subtotal (Total Children Is Unduplicated) 94 575.000000 21390.0000 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 2 2.000000 161.9600 80.9800
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.500000 269.6400 59.9200
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 1 1.000000 80.9800 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 10.500000 850.2900 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 28 34.500000 2793.8100 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 9.000000 728.8200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 19.500000 1579.1100 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 23.000000 1378.1600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 58 90.500000 5422.7600 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 28.500000 2307.9300 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 65.000000 5263.7000 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.000000 3485.7000 151.5522
Subtotal (Total Children Is Unduplicated) 86 314.500000 24606.2900 78.2394
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Total 889.500000 45996.2900 51.7103
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Number of Children (Unduplicated) With at Least One Service 99
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Center 04
Flag Claims Units Chgs Paid
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R 7 14.500000 539.4000 0.0000
U 0 0.000000 0.0000 0.0000
B 148 256.500000 11433.7300 0.0000
P 31 57.750000 2458.0800 2435.7200
D 7 10.500000 500.8800 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
439 550.250000 31064.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 632 889.500000 45996.2900 2435.7200