CMS/EIP Fiscal Report Statewide
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: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 54 75.500000 3385.2400 44.8376
Subtotal (Total Children Is Unduplicated) 54 75.500000 3385.2400 44.8376
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 13.500000 1093.2300 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 25 33.000000 2672.3400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 13.000000 1052.7400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 17 27.000000 2186.4600 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 20 29.000000 1737.6800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 47 60.500000 3625.1600 59.9200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 160.6500 53.5500
Subtotal (Total Children Is Unduplicated) 74 180.500000 12649.7300 70.0816
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Total 256.000000 16034.9700 62.6366
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Number of Children (Unduplicated) With at Least One Service 74
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Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
14 14.000000 819.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14 14.000000 819.7700 0.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 5 9.500000 769.3100 769.3100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 162 226.500000 14023.1900 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 167 236.000000 14792.5000 769.3100
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
4 6.000000 422.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4 6.000000 422.7000 0.0000