CMS/EIP Fiscal Report Center: 52
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 438 1203.500000 54179.8600 45.0186
Subtotal (Total Children Is Unduplicated) 438 1203.500000 54179.8600 45.0186
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 971.7600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 485.8800 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 359.5200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 86.000000 6964.2800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 36.000000 2915.2800 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 24.000000 1943.5200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 110.000000 6591.2000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 479.3600 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
SCREEN-T1023-SCREENING 6 6.000000 323.8800 53.9800
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 6 11.000000 639.2100 58.1100
Subtotal (Total Children Is Unduplicated) 104 318.000000 22528.0400 70.8429
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 278 1227.750000 66312.0000 54.0110
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 17 42.000000 3415.4400 81.3200
OCCT-97530TLHM-OT SESSION BY OT ASST 5 16.000000 1041.9200 65.1200
PHY-97110HM-PT SESSION BY PT ASST 1 1.500000 97.6800 65.1200
PHY-97110TL-PT SESSION BY LICENSED PT 25 65.500000 5326.4600 81.3200
PHY-97110TLHM-PT SESSION BY PT ASST 8 37.000000 2409.4400 65.1200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 25 78.750000 6403.9500 81.3200
Subtotal (Total Children Is Unduplicated) 317 1469.500000 85088.2100 57.9028
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Total 2991.000000 161796.1100 54.0943
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Number of Children (Unduplicated) With at Least One Service 537
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Center 52
Flag Claims Units Chgs Paid
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R 23 15.250000 746.5400 0.0000
U 0 0.000000 0.0000 0.0000
B 903 945.000000 49050.2400 0.0000
P 755 843.250000 47831.6500 47517.2500
D 0 0.000000 0.0000 0.0000
S 215 196.000000 8871.8600 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 54.0000 15.0000
892 951.000000 53443.8200 0.0000
Other 52 39.500000 1798.0000 0.0000
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Total 2841 2991.000000 161796.1100 47532.2500