CMS/EIP Fiscal Report Center: 51
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
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 242.9400 80.9800
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.500000 1093.2300 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 59.9200 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 8.500000 688.3300 80.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 16 30.500000 2425.9600 79.5397
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 80 321.000000 17334.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 33 92.000000 7481.4400 81.3200
PHY-97110-PT SESSION BY LICENSED PT 16 56.250000 4574.2500 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 125.750000 10225.9900 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 162.6400 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
Subtotal (Total Children Is Unduplicated) 133 598.000000 39859.6400 66.6549
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Total 628.500000 42285.6000 67.2802
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Number of Children (Unduplicated) With at Least One Service 145
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Center 51
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 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
621 628.500000 42285.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 621 628.500000 42285.6000 0.0000