CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 Page: 1
List order: No List
Payclass Filters:MED
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 31 120.000000 5365.0000 44.7083
Subtotal (Total Children Is Unduplicated) 31 120.000000 5365.0000 44.7083
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 80.9800 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 9.500000 769.3100 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 9.500000 769.3100 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 5.500000 445.3900 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 15.000000 1214.7000 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 202.4500 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 10.500000 629.1600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.000000 299.6000 59.9200
Subtotal (Total Children Is Unduplicated) 27 61.000000 4613.3500 75.6287
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Total 181.000000 9978.3500 55.1290
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Number of Children (Unduplicated) With at Least One Service 31
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Center 06
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 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
186 181.000000 9978.3500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 186 181.000000 9978.3500 0.0000