CMS/EIP Fiscal Report Center: 01
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 280 558.500000 25478.0200 45.6187
Subtotal (Total Children Is Unduplicated) 280 558.500000 25478.0200 45.6187
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.000000 647.8400 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 5 8.500000 509.3200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 404.9000 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 63 109.500000 8867.3100 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 24 42.500000 3441.6500 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 27.500000 2226.9500 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 24 43.000000 3482.1400 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 27.000000 2186.4600 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 18.000000 1457.6400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 67 110.500000 6621.1600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 24 42.000000 2516.6400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 25.000000 2024.5000 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 38.500000 3198.7100 83.0834
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 211 510.000000 37925.1300 74.3630
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 41 119.250000 6439.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 5 5.750000 310.5000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 5.000000 406.6000 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.000000 243.9600 81.3200
PHY-97110-PT SESSION BY LICENSED PT 7 8.000000 650.5600 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 6.000000 487.9200 81.3200
Subtotal (Total Children Is Unduplicated) 62 147.000000 8539.0400 58.0887
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Total 1215.500000 71942.1900 59.1873
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Number of Children (Unduplicated) With at Least One Service 493
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Center 01
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 142 155.750000 8893.6900 0.0000
S 344 258.500000 13589.9200 0.0000
H 718 788.500000 48722.9300 48722.9300
T 0 0.000000 0.0000 0.0000
8 7.500000 442.8800 0.0000
Other 7 5.250000 292.7700 0.0000
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Total 1219 1215.500000 71942.1900 48722.9300