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:GR
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 24 124.500000 5678.6800 45.6119
Subtotal (Total Children Is Unduplicated) 39 148.250000 6763.5800 45.6228
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 119.8400 59.9200
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 80.9800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 9.500000 569.2400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 12 13.000000 778.9600 59.9200
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 80.9800 80.9800
Subtotal (Total Children Is Unduplicated) 23 27.500000 1710.9800 62.2175
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Total 175.750000 8474.5600 48.2194
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Number of Children (Unduplicated) With at Least One Service 44
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Center 04
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
123 175.750000 8474.5600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 123 175.750000 8474.5600 0.0000