CMS/EIP Fiscal Report Center: 06
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 9 29.000000 1443.9800 49.7924
Subtotal (Total Children Is Unduplicated) 9 29.000000 1443.9800 49.7924
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 283.4300 80.9800
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 209.7200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 40.000000 3239.2000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 30 39.500000 3198.7100 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 20.000000 1619.6000 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 26 36.000000 2915.2800 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 11.000000 890.7800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 8.000000 647.8400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 33.000000 1977.3600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 20 30.500000 1827.5600 59.9200
Subtotal (Total Children Is Unduplicated) 105 226.000000 16890.4600 74.7365
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 118.000000 6353.2000 53.8407
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 14.000000 756.0000 54.0000
OCCT-97530GO-OT SESSION BY LICENSED OT 1 5.500000 447.2600 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 2 3.000000 243.9600 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 2 5.000000 325.6000 65.1200
OCCT-97530HMGT-OT SESSION BY OT ASST 1 0.750000 48.8400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 5 54.000000 4391.2800 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110HM-PT SESSION BY PT ASST 3 23.250000 1367.5200 58.8181
PHY-97110HMGT-PT SESSION BY PT ASST 3 11.000000 716.3200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 62.500000 4611.6200 73.7859
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 32.750000 2663.2300 81.3200
Subtotal (Total Children Is Unduplicated) 48 330.750000 22006.1500 66.5341
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Total 585.750000 40340.5900 68.8700
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Number of Children (Unduplicated) With at Least One Service 152
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Center 06
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 102 100.000000 6967.0200 6967.0200
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
457 485.750000 33373.5700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 559 585.750000 40340.5900 6967.0200