CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 371 617.750000 28218.8200 45.6800
Subtotal (Total Children Is Unduplicated) 371 617.750000 28218.8200 45.6800
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 179.7600 59.9200
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 35.000000 2097.2000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 26.000000 2105.4800 80.9800
SCREEN-T1023-SCREENING 9 9.000000 485.8200 53.9800
Subtotal (Total Children Is Unduplicated) 40 77.000000 5107.9400 66.3369
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Total 694.750000 33326.7600 47.9694
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Number of Children (Unduplicated) With at Least One Service 381
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Center 03
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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 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
1015 694.750000 33326.7600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1015 694.750000 33326.7600 0.0000