CMS/EIP Fiscal Report Center: 54
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 69 396.750000 17773.2000 44.7970
Subtotal (Total Children Is Unduplicated) 69 396.750000 17773.2000 44.7970
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
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 2 4.000000 239.6800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 28.500000 2307.9300 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 11.500000 931.2700 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1133.7200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 25.000000 1498.0000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 16 29.500000 1767.6400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 701.8400 70.1840
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 23.500000 1903.0300 80.9800
Subtotal (Total Children Is Unduplicated) 55 158.000000 11412.7500 72.2326
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Total 554.750000 29185.9500 52.6110
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Number of Children (Unduplicated) With at Least One Service 70
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Center 54
Flag Claims Units Chgs Paid
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R 5 8.250000 251.2400 0.0000
U 0 0.000000 0.0000 0.0000
B 213 274.750000 13905.3600 0.0000
P 128 158.750000 8245.6400 8082.8000
D 8 8.750000 399.7000 325.5000
S 25 24.250000 1090.7800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
38 68.500000 4767.9100 0.0000
Other 8 11.500000 525.3200 399.9000
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Total 425 554.750000 29185.9500 8808.2000