CMS/EIP Fiscal Report Center: 05
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
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 283.4300 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 5 13.000000 526.0200 40.4631
Subtotal (Total Children Is Unduplicated) 15 25.500000 1378.1800 54.0463
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 27.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 18.500000 999.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 53.500000 4234.4600 79.1488
OCCT-97530GO-OT SESSION BY LICENSED OT 2 5.000000 406.6000 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 6.000000 487.9200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 30 97.000000 6585.9400 67.8963
PHY-97110GP-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 67.250000 4901.1900 72.8801
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 76.0200 38.0100
Subtotal (Total Children Is Unduplicated) 77 252.250000 17849.4500 70.7610
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Total 277.750000 19227.6300 69.2264
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Number of Children (Unduplicated) With at Least One Service 85
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Center 05
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 299 268.750000 18546.2800 18546.2800
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
9 9.000000 681.3500 681.3500
Other 0 0.000000 0.0000 0.0000
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Total 308 277.750000 19227.6300 19227.6300