CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 Page: 1
List order: No List
Payclass Filters:TPIN
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 1 1.000000 45.6800 45.6800
Subtotal (Total Children Is Unduplicated) 1 1.000000 45.6800 45.6800
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 809.8000 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 526.3700 80.9800
Subtotal (Total Children Is Unduplicated) 8 16.500000 1336.1700 80.9800
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 108.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 1 1.000000 15.0000 15.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 8.000000 486.9600 60.8700
PHY-97110-PT SESSION BY LICENSED PT 2 4.000000 267.2700 66.8175
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 50.500000 3649.7100 72.2715
Subtotal (Total Children Is Unduplicated) 21 65.500000 4526.9400 69.1136
-----------------------------------------------------------------------------------------------------------------------
Total 83.000000 5908.7900 71.1902
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 30
-----------------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
76 83.000000 5908.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 76 83.000000 5908.7900 0.0000