CMS/EIP Fiscal Report Center: 09
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 8 11.500000 931.2700 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 17 27.000000 2186.4600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 25.000000 1498.0000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 37 50.500000 3025.9600 59.9200
Subtotal (Total Children Is Unduplicated) 59 160.500000 11407.2600 71.0733
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Total 236.000000 14792.5000 62.6801
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Number of Children (Unduplicated) With at Least One Service 59
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Center 09
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 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
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Total 167 236.000000 14792.5000 769.3100