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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.000000 161.9600 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 3.000000 242.9400 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 2.500000 202.4500 80.9800
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 404.9000 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 4 5.000000 404.9000 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 15.000000 1214.7000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 38 44.000000 3563.1200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.000000 404.9000 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 25.000000 2024.5000 80.9800
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 29.500000 2388.9100 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 93.000000 7531.1400 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 7 7.000000 2128.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 17.7800 17.7800
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 88 240.000000 20999.4200 87.4976
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 3 11.000000 754.5200 68.5927
OCCT-97530HM-OT SESSION BY OT ASST 1 5.000000 325.6000 65.1200
PHY-97110HM-PT SESSION BY PT ASST 1 8.000000 520.9600 65.1200
Subtotal (Total Children Is Unduplicated) 5 24.000000 1601.0800 66.7117
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Total 264.000000 22600.5000 85.6080
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Number of Children (Unduplicated) With at Least One Service 91
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Center 04
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 4 4.000000 121.7400 121.7400
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
202 238.000000 20923.5300 0.0000
Other 22 22.000000 1555.2300 0.0000
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Total 228 264.000000 22600.5000 121.7400