CMS/EIP Fiscal Report Center: 52
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 34 147.000000 6712.8400 45.6656
Subtotal (Total Children Is Unduplicated) 34 147.000000 6712.8400 45.6656
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 119.8400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1133.7200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 647.8400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 32.000000 1917.4400 59.9200
Subtotal (Total Children Is Unduplicated) 21 60.000000 4100.6400 68.3440
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Total 207.000000 10813.4800 52.2390
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Number of Children (Unduplicated) With at Least One Service 34
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Center 52
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 51 80.250000 4231.8200 0.0000
P 41 65.750000 3768.8200 3700.9800
D 0 0.000000 0.0000 0.0000
S 41 37.500000 1710.8800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
15 23.500000 1101.9600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 148 207.000000 10813.4800 3700.9800