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
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 31 172.750000 7853.0600 45.4591
Subtotal (Total Children Is Unduplicated) 31 172.750000 7853.0600 45.4591
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 10.000000 809.8000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 8.500000 688.3300 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.000000 323.9200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 7.000000 566.8600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 7.500000 449.4000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 16 17.500000 1048.6000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 8.500000 688.3300 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 9.000000 728.8200 80.9800
Subtotal (Total Children Is Unduplicated) 26 72.000000 5304.0600 73.6675
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Total 244.750000 13157.1200 53.7574
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Number of Children (Unduplicated) With at Least One Service 37
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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
41 47.500000 3509.5900 0.0000
Other 1 2.500000 114.2000 0.0000
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Total 149 244.750000 13157.1200 2584.4000