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
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 665 2429.750000 110990.9800 45.6800
Subtotal (Total Children Is Unduplicated) 665 2429.750000 110990.9800 45.6800
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 24.000000 1943.5200 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 13 22.000000 1318.2400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 38.500000 3117.7300 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 111 195.500000 15831.5900 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 7.500000 607.3500 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 12.000000 971.7600 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 142 256.500000 15369.4800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 10.000000 599.2000 59.9200
Subtotal (Total Children Is Unduplicated) 175 572.500000 40253.6500 70.3121
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Total 3002.250000 151244.6300 50.3771
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Number of Children (Unduplicated) With at Least One Service 678
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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 1779 2843.000000 143120.7900 143120.7900
T 0 0.000000 0.0000 0.0000
102 159.250000 8123.8400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1881 3002.250000 151244.6300 143120.7900