CMS/EIP Fiscal Report Center: 53
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 31 140.000000 6308.7600 45.0626
Subtotal (Total Children Is Unduplicated) 31 140.000000 6308.7600 45.0626
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 24.000000 1943.5200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.500000 607.3500 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 728.8200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.000000 647.8400 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.500000 445.3900 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.000000 1198.4000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 14.500000 868.8400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 242.9400 80.9800
Subtotal (Total Children Is Unduplicated) 32 93.000000 6804.5700 73.1674
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Total 233.000000 13113.3300 56.2804
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Number of Children (Unduplicated) With at Least One Service 33
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Center 53
Flag Claims Units Chgs Paid
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R 2 2.250000 102.7800 0.0000
U 0 0.000000 0.0000 0.0000
B 107 138.250000 7979.5700 0.0000
P 36 50.250000 2523.4100 2489.4900
D 6 5.500000 251.2400 204.6000
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 28.750000 1841.4900 0.0000
Other 8 8.000000 414.8400 83.7000
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Total 177 233.000000 13113.3300 2777.7900