CMS/EIP Fiscal Report Center: 57
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 34 213.750000 9764.1000 45.6800
Subtotal (Total Children Is Unduplicated) 34 213.750000 9764.1000 45.6800
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.000000 890.7800 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 33.000000 2672.3400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.000000 647.8400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 48.500000 2906.1200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
Subtotal (Total Children Is Unduplicated) 33 108.500000 7680.6800 70.7897
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 6.000000 324.0000 54.0000
Subtotal (Total Children Is Unduplicated) 1 6.000000 324.0000 54.0000
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Total 328.250000 17768.7800 54.1319
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Number of Children (Unduplicated) With at Least One Service 35
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Center 57
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 152 281.250000 15317.0800 15317.0800
T 0 0.000000 0.0000 0.0000
26 47.000000 2451.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 178 328.250000 17768.7800 15317.0800