CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 83 82.250000 3591.8200 43.6695
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 34 38.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 122 504.250000 22631.6200 44.8817
Subtotal (Total Children Is Unduplicated) 129 624.500000 26223.4400 41.9911
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 2105.4800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 20.000000 1619.6000 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1295.6800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 479.3600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
Subtotal (Total Children Is Unduplicated) 26 72.000000 5619.9600 78.0550
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Total 696.500000 31843.4000 45.7192
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Number of Children (Unduplicated) With at Least One Service 129
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Center 55
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 16 32.000000 2380.7600 2380.7600
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 2 4.000000 323.9200 323.9200
613 660.500000 29138.7200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 631 696.500000 31843.4000 2704.6800