CMS/EIP Fiscal Report Center: 10
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 112 487.000000 21983.4200 45.1405
Subtotal (Total Children Is Unduplicated) 112 487.000000 21983.4200 45.1405
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Screening, Eval, and Assessment,Class #02
AUDE-92558-OTOACOUSTIC EMISSIONS (SCREENING) 1 1.000000 6.8700 6.8700
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.000000 566.8600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 80 132.500000 10729.8500 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.500000 445.3900 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 22.000000 1781.5600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 202.4500 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 32.500000 2631.8500 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 108.000000 6471.3600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.500000 269.6400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 22.500000 1822.0500 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
Subtotal (Total Children Is Unduplicated) 97 349.000000 25776.5400 73.8583
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Total 836.000000 47759.9600 57.1291
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Number of Children (Unduplicated) With at Least One Service 112
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Center 10
Flag Claims Units Chgs Paid
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R 18 21.250000 1099.4500 0.0000
U 0 0.000000 0.0000 0.0000
B 584 796.750000 45566.1000 0.0000
P 7 9.750000 717.5500 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
1 0.250000 11.4200 0.0000
Other 9 8.000000 365.4400 0.0000
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Total 619 836.000000 47759.9600 0.0000