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
Agency Filter:EIP DEI DEIP
Payclass Filters:OTHER
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 117 166.500000 7559.0800 45.3999
Subtotal (Total Children Is Unduplicated) 117 166.500000 7559.0800 45.3999
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 59.9200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.000000 239.6800 59.9200
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 3 6.000000 485.8800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.000000 719.0400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 36 46.500000 2786.2800 59.9200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 22 22.000000 1178.1000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 102.8700 34.2900
Subtotal (Total Children Is Unduplicated) 68 100.500000 6057.6500 60.2751
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 6.000000 324.0000 54.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 6.000000 72.0000 12.0000
TRAV-TRAVS-Travel by mile 1 139.000000 61.8400 0.4449
Subtotal (Total Children Is Unduplicated) 1 151.000000 457.8400 3.0321
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Total 418.000000 14074.5700 33.6712
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Number of Children (Unduplicated) With at Least One Service 186
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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
67 79.000000 4516.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 67 79.000000 4516.6500 0.0000
Center 07
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
0 0.000000 0.0000 0.0000
Other 63 23.500000 1026.8400 0.0000
---------------------------------------------------------
Total 63 23.500000 1026.8400 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 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
6 7.000000 319.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 7.000000 319.7600 0.0000
Center 52
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
18 151.000000 457.8400 379.8400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18 151.000000 457.8400 379.8400
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
18 28.250000 1849.3400 0.0000
Other 116 129.250000 5904.1400 0.0000
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Total 134 157.500000 7753.4800 0.0000