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: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 5 9.000000 411.1200 45.6800
Subtotal (Total Children Is Unduplicated) 5 9.000000 411.1200 45.6800
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 239.6800 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 179.7600 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 35.000000 2834.3000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.000000 728.8200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.500000 1255.1900 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 12.500000 1012.2500 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 16.500000 1336.1700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 34.500000 2067.2400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 445.3900 80.9800
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 9.000000 522.9900 58.1100
Subtotal (Total Children Is Unduplicated) 62 158.500000 11685.7000 73.7268
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 1 0.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 65.500000 3537.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 6.000000 324.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 69.750000 5672.0700 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 16 69.000000 5611.0800 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 3 5.000000 406.6000 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 162.6400 81.3200
PHY-97110-PT SESSION BY LICENSED PT 33 146.000000 12031.4000 82.4068
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 1 3.000000 243.9600 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 49 218.000000 17739.5600 81.3741
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 27.750000 2256.6300 81.3200
Subtotal (Total Children Is Unduplicated) 126 613.500000 48066.2600 78.3476
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Total 781.000000 60163.0800 77.0334
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Number of Children (Unduplicated) With at Least One Service 173
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Center 53
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 14 9.240000 912.8100 816.8100
D 102 109.760000 7810.7100 0.0000
S 4 4.000000 325.2800 0.0000
H 88 89.500000 7222.3100 0.0000
T 7 7.000000 514.6000 514.6000
525 559.500000 43214.7300 0.0000
Other 2 2.000000 162.6400 0.0000
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Total 742 781.000000 60163.0800 1331.4100