CMS/EIP Fiscal Report Center: 53
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 635 1700.250000 76829.1400 45.1870
Subtotal (Total Children Is Unduplicated) 635 1700.250000 76829.1400 45.1870
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Screening, Eval, and Assessment,Class #02
AACIS-92597TL-AAC INTIAL EVAL BY LICENSED SLP 2 2.000000 233.6600 116.8300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 769.3100 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.500000 607.3500 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 9.500000 569.2400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 70.500000 5628.1100 79.8313
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 33 59.000000 4777.8200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 44.000000 3563.1200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 29.000000 2316.8300 79.8907
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 46.000000 3725.0800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 11.500000 931.2700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 50 93.000000 5563.7200 59.8249
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 40 72.000000 4314.2400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 23.500000 1903.0300 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 445.3900 80.9800
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 58.1100 58.1100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 3 23.000000 1336.5300 58.1100
Subtotal (Total Children Is Unduplicated) 165 510.500000 37066.7300 72.6087
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 334 1293.500000 69849.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 68 109.500000 5913.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 25.000000 2033.0000 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 6 8.000000 650.5600 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 2 5.000000 406.6000 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.000000 243.9600 81.3200
OCCT-97530TL-OT SESSION BY LICENSED OT 3 8.000000 650.5600 81.3200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 50 170.250000 13844.7300 81.3200
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 13 12.500000 1016.5000 81.3200
PHY-97110-PT SESSION BY LICENSED PT 2 2.000000 162.6400 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 47 205.500000 16711.2600 81.3200
PHY-97110TLGP-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110TLGPGT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.500000 40.6600 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 20.000000 1626.4000 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 4.250000 345.6100 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 61 261.750000 21285.5100 81.3200
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 17 29.750000 2326.9600 78.2171
Subtotal (Total Children Is Unduplicated) 489 2161.500000 137350.9100 63.5443
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Total 4372.250000 251246.7800 57.4640
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Number of Children (Unduplicated) With at Least One Service 807
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Center 53
Flag Claims Units Chgs Paid
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R 141 120.000000 6361.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 1714 1655.750000 96766.1300 37.2000
P 997 941.000000 56263.5400 55806.4200
D 129 109.500000 5156.7300 3844.6400
S 42 40.250000 2818.2100 0.0000
H 4 4.250000 265.4200 0.0000
T 0 0.000000 0.0000 0.0000
1287 1351.250000 76550.2400 0.0000
Other 215 150.250000 7065.2100 432.8200
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Total 4529 4372.250000 251246.7800 60121.0800