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
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 629 704.250000 26198.1000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1113 4649.000000 172942.8000 37.2000
Subtotal (Total Children Is Unduplicated) 1152 5353.250000 199140.9000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 10 8.000000 400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 8.500000 688.3300 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 13.500000 1093.2300 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 242.9400 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 6.000000 485.8800 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 11.000000 659.1200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 27.500000 1647.8000 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 6 9.000000 728.8200 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 7 8.000000 647.8400 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 49.000000 3968.0200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 146 200.500000 16236.4900 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 19.500000 1579.1100 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 70 91.000000 7369.1800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 67 90.000000 5392.8000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 214 354.500000 21241.6400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 84.500000 6842.8100 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 113 177.000000 14333.4600 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 64 64.000000 8185.7500 127.9023
Subtotal (Total Children Is Unduplicated) 333 1224.500000 91743.2200 74.9230
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 54.0000 54.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 12.0000 12.0000
Subtotal (Total Children Is Unduplicated) 1 2.000000 66.0000 33.0000
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Total 6579.750000 290950.1200 44.2190
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Number of Children (Unduplicated) With at Least One Service 1203
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Center 04
Flag Claims Units Chgs Paid
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R 116 195.750000 7281.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 1566 2540.250000 102491.4600 0.0000
P 346 578.000000 24750.0900 25246.1100
D 27 47.750000 1810.3800 0.0000
S 1 3.000000 111.6000 0.0000
H 1 1.000000 54.0000 0.0000
T 0 0.000000 0.0000 0.0000
2637 3209.500000 154283.2900 0.0000
Other 4 4.500000 167.4000 0.0000
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Total 4698 6579.750000 290950.1200 25246.1100