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
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 27 23.750000 1084.9000 45.6800
TCM-T1017TL-TARGETED CASE MANAGEMENT 55 297.250000 13531.7400 45.5231
Subtotal (Total Children Is Unduplicated) 55 321.000000 14616.6400 45.5347
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 119.8400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 20.500000 1660.0900 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 17.500000 1417.1500 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 7.500000 607.3500 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 9 9.000000 728.8200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 18.000000 1078.5600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 40.500000 2426.7600 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 28.500000 2307.9300 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 27.000000 2186.4600 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 768.6500 153.7300
Subtotal (Total Children Is Unduplicated) 53 179.500000 13625.5300 75.9082
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Total 500.500000 28242.1700 56.4279
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Number of Children (Unduplicated) With at Least One Service 68
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Center 04
Flag Claims Units Chgs Paid
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R 10 23.000000 1050.6400 0.0000
U 0 0.000000 0.0000 0.0000
B 67 121.250000 5767.2500 0.0000
P 30 50.500000 2715.4400 2584.4000
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
234 303.250000 18594.6400 0.0000
Other 1 2.500000 114.2000 0.0000
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Total 342 500.500000 28242.1700 2584.4000