CMS/EIP Fiscal Report Center: 04
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: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 660 2286.750000 103572.5800 45.2925
Subtotal (Total Children Is Unduplicated) 660 2286.750000 103572.5800 45.2925
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 7.500000 607.3500 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 8.500000 688.3300 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 5.500000 445.3900 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 10.500000 629.1600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 12.500000 749.0000 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 6 14.500000 1174.2100 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 3 4.500000 364.4100 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 22.500000 1822.0500 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 85 99.000000 8017.0200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 10.000000 744.1300 74.4130
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 44 50.000000 4049.0000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 24.500000 1445.3200 58.9927
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 121 143.500000 8598.5200 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 46.500000 3721.7900 80.0385
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 43.500000 3522.6300 80.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 348.6600 58.1100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 4 4.000000 232.4400 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 174.3300 58.1100
Subtotal (Total Children Is Unduplicated) 196 520.000000 37611.9200 72.3306
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 702 4728.000000 255312.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 35.000000 1890.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 19.750000 1606.0700 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 3 10.000000 651.2000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110HM-PT SESSION BY PT ASST 13 69.000000 4493.2800 65.1200
PHY-97110TLHM-PT SESSION BY PT ASST 1 6.000000 390.7200 65.1200
Subtotal (Total Children Is Unduplicated) 718 4868.750000 264424.5900 54.3106
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Total 7675.500000 405609.0900 52.8446
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Number of Children (Unduplicated) With at Least One Service 1092
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Center 04
Flag Claims Units Chgs Paid
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R 103 181.250000 8293.7400 0.0000
U 0 0.000000 0.0000 0.0000
B 926 1522.000000 72134.7000 0.0000
P 513 825.750000 41412.0000 39425.4700
D 11 20.000000 1036.4100 0.0000
S 0 0.000000 0.0000 0.0000
H 4876 4875.750000 264754.7200 0.0000
T 0 0.000000 0.0000 0.0000
209 248.750000 17875.2000 0.0000
Other 2 2.000000 102.3200 0.0000
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Total 6640 7675.500000 405609.0900 39425.4700