CMS/EIP Fiscal Report Center: 09
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 723 2101.500000 95705.8200 45.5417
Subtotal (Total Children Is Unduplicated) 723 2101.500000 95705.8200 45.5417
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 364.4100 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 242.9400 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 269.6400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.000000 419.4400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 26.500000 2145.9700 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 30 53.000000 4249.8200 80.1853
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 51.000000 4129.9800 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 62 118.000000 9474.6600 80.2937
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 29.500000 2388.9100 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 29 55.500000 4494.3900 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 58 105.500000 6321.5600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 119 223.000000 13302.2400 59.6513
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 187 686.000000 48185.9900 70.2420
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 711 3812.500000 205767.0000 53.9717
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 10.000000 540.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 204.000000 16589.2800 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 16 70.000000 4623.2000 66.0457
OCCT-97530HMGT-OT SESSION BY OT ASST 1 3.000000 195.3600 65.1200
PHY-97110-PT SESSION BY LICENSED PT 27 103.000000 8375.9600 81.3200
PHY-97110HM-PT SESSION BY PT ASST 3 25.000000 1628.0000 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 177.000000 14393.6400 81.3200
Subtotal (Total Children Is Unduplicated) 752 4404.500000 252112.4400 57.2397
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Total 7192.000000 396004.2500 55.0618
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Number of Children (Unduplicated) With at Least One Service 1066
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Center 09
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 0 0.000000 0.0000 0.0000
D 11 11.000000 621.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 1173 1477.000000 74771.1700 74771.1700
T 0 0.000000 0.0000 0.0000
5326 5565.000000 311321.3900 0.0000
Other 73 139.000000 9290.3700 0.0000
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Total 6583 7192.000000 396004.2500 74771.1700