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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 691 2459.500000 111425.6400 45.3042
Subtotal (Total Children Is Unduplicated) 691 2459.500000 111425.6400 45.3042
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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 28 32.500000 2631.8500 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 93 107.500000 8705.3500 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 14.000000 1068.0500 76.2893
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 51 57.000000 4615.8600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 32.000000 1894.7200 59.2100
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 137 161.000000 9647.1200 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 55.000000 4410.1200 80.1840
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 52.500000 4251.4500 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) 222 592.000000 42915.9800 72.4932
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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 7920.250000 418766.2100 52.8729
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Number of Children (Unduplicated) With at Least One Service 1129
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Center 04
Flag Claims Units Chgs Paid
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R 113 204.250000 9344.3800 0.0000
U 0 0.000000 0.0000 0.0000
B 993 1643.250000 77901.9500 0.0000
P 543 876.250000 44127.4400 42009.8700
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
250 296.250000 21384.7900 0.0000
Other 3 4.500000 216.5200 0.0000
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Total 6789 7920.250000 418766.2100 42009.8700