CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 686 2439.750000 110567.9800 45.3194
Subtotal (Total Children Is Unduplicated) 686 2439.750000 110567.9800 45.3194
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 22.000000 1781.5600 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 57 65.000000 5263.7000 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 5.500000 379.7200 69.0400
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 25 27.500000 2226.9500 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 21.500000 1265.5600 58.8633
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 71 81.000000 4853.5200 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 36.500000 2911.9900 79.7805
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 24.000000 1943.5200 80.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 110 285.000000 20744.5500 72.7879
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 243.9600 81.3200
Subtotal (Total Children Is Unduplicated) 1 3.000000 243.9600 81.3200
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Total 2727.750000 131556.4900 48.2289
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Number of Children (Unduplicated) With at Least One Service 707
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Center 04
Flag Claims Units Chgs Paid
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R 113 204.250000 9344.3800 0.0000
U 0 0.000000 0.0000 0.0000
B 995 1647.250000 78084.6700 0.0000
P 543 876.250000 44127.4400 42009.8700
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1651 2727.750000 131556.4900 42009.8700