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
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 586 2145.000000 97103.8000 45.2698
Subtotal (Total Children Is Unduplicated) 586 2145.000000 97103.8000 45.2698
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Screening, Eval, and Assessment,Class #02
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 8 8.500000 688.3300 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 2 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 10.500000 629.1600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 12.500000 749.0000 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 6 14.500000 1174.2100 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 3 4.500000 364.4100 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 22.500000 1822.0500 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 85 99.000000 8017.0200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 10.000000 744.1300 74.4130
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 44 50.000000 4049.0000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 24.500000 1445.3200 58.9927
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 121 143.500000 8598.5200 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 46.500000 3721.7900 80.0385
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 43.500000 3522.6300 80.9800
Subtotal (Total Children Is Unduplicated) 189 505.000000 36740.2700 72.7530
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Total 2650.000000 133844.0700 50.5072
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Number of Children (Unduplicated) With at Least One Service 632
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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
205 245.250000 17678.0300 0.0000
Other 1 1.000000 37.2000 0.0000
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Total 1625 2650.000000 133844.0700 38751.6900