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
Agency Filter:EIP DEI DEIP
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 417 352.250000 16069.5800 45.6198
TCM-T1017TL-TARGETED CASE MANAGEMENT 823 3029.000000 137484.9200 45.3895
Subtotal (Total Children Is Unduplicated) 845 3381.250000 153554.5000 45.4135
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 4 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 7.500000 607.3500 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 12 13.500000 1093.2300 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 5.500000 445.3900 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 364.4100 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 9 13.000000 778.9600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 15 22.000000 1318.2400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 7 17.500000 1417.1500 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 7 9.500000 769.3100 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 29.500000 2388.9100 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 123 142.500000 11539.6500 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 12.000000 906.0900 75.5075
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 66 75.000000 6073.5000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 32.500000 1924.6800 59.2209
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 161 237.000000 14201.0400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 57.000000 4572.0800 80.2119
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 83 123.500000 10001.0300 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 27 27.000000 2698.1000 99.9296
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 295.8700 73.9675
Subtotal (Total Children Is Unduplicated) 255 837.000000 61594.9900 73.5902
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Total 4218.250000 215149.4900 51.0044
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Number of Children (Unduplicated) With at Least One Service 904
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Center 04
Flag Claims Units Chgs Paid
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R 80 156.750000 7174.5800 0.0000
U 0 0.000000 0.0000 0.0000
B 832 1420.750000 67509.6000 0.0000
P 497 807.000000 40436.1500 38751.6900
D 10 19.250000 1008.5100 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
1600 1813.500000 98983.4500 0.0000
Other 1 1.000000 37.2000 0.0000
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Total 3020 4218.250000 215149.4900 38751.6900