CMS/EIP Fiscal Report Center: 54
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 848 2618.000000 117729.3800 44.9692
Subtotal (Total Children Is Unduplicated) 848 2618.000000 117729.3800 44.9692
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 116.8300 116.8300
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 485.8800 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 479.3600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.500000 449.4000 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.000000 1214.7000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 971.7600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 35.000000 2834.3000 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 22.000000 1781.5600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 27.500000 2226.9500 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 23.000000 1862.5400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 41 74.000000 4434.0800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 34 62.500000 3745.0000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 50.000000 4049.0000 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 40.500000 3279.6900 80.9800
SCREEN-T1023-SCREENING 1 1.000000 53.9800 53.9800
Subtotal (Total Children Is Unduplicated) 127 395.000000 28794.8300 72.8983
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 47.9400 47.9400
AACFIT-92609TL-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 47.9400 47.9400
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 14 22.000000 594.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 412 1609.000000 86993.9600 54.0671
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 67 92.000000 4968.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 4.000000 325.2800 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 8 18.000000 1463.7600 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 65.1200 65.1200
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 60 199.000000 16182.6800 81.3200
OCCT-97530TLGOGT-OT SESSION BY LICENSED OT 3 3.000000 243.9600 81.3200
OCCT-97530TLGTHM-OT SESSION BY OT ASST 6 9.000000 586.0800 65.1200
OCCT-97530TLHM-OT SESSION BY OT ASST 17 73.000000 4753.7600 65.1200
PHY-97110-PT SESSION BY LICENSED PT 21 67.500000 5489.1000 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 48 179.750000 14617.2700 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 2 2.000000 162.6400 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 110.500000 8985.8600 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 243.9600 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 35 52.000000 4228.6400 81.3200
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 162.6400 81.3200
Subtotal (Total Children Is Unduplicated) 577 2451.750000 150406.5500 61.3466
-----------------------------------------------------------------------------------------------------------------------
Total 5464.750000 296930.7600 54.3357
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 925
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 79 73.250000 4100.7800 0.0000
U 0 0.000000 0.0000 0.0000
B 2087 1922.000000 100133.4600 0.0000
P 1265 1156.000000 63804.5500 63172.4700
D 192 167.750000 7896.1000 5907.6400
S 104 86.750000 3865.2200 0.0000
H 4 3.750000 206.9400 0.0000
T 0 0.000000 0.0000 0.0000
1775 1860.250000 107826.6500 0.0000
Other 288 195.000000 9097.0600 1226.0400
---------------------------------------------------------
Total 5794 5464.750000 296930.7600 70306.1500