CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 74 136.000000 6212.4800 45.6800
Subtotal (Total Children Is Unduplicated) 74 136.000000 6212.4800 45.6800
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 485.8800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.500000 769.3100 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.500000 749.0000 59.9200
Subtotal (Total Children Is Unduplicated) 8 29.500000 2125.6600 72.0563
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 5.000000 135.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 18.000000 972.0000 54.0000
Subtotal (Total Children Is Unduplicated) 10 25.000000 1207.0000 48.2800
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Total 190.500000 9545.1400 50.1057
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Number of Children (Unduplicated) With at Least One Service 92
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Center 57
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 2 2.000000 100.0000 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
46 59.250000 3541.0000 0.0000
Other 116 129.250000 5904.1400 0.0000
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Total 164 190.500000 9545.1400 0.0000