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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 917 3014.750000 135502.5800 44.9465
Subtotal (Total Children Is Unduplicated) 917 3014.750000 135502.5800 44.9465
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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 4 8.000000 647.8400 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 599.2000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.500000 689.0800 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 9 17.000000 1376.6600 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1133.7200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 63.500000 5142.2300 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 17 33.500000 2712.8300 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 29.500000 2388.9100 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 19 37.000000 2996.2600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 99.000000 5932.0800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 50 92.000000 5512.6400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 60.000000 4750.8400 79.1807
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 64.000000 5182.7200 80.9800
SCREEN-T1023-SCREENING 1 1.000000 53.9800 53.9800
Subtotal (Total Children Is Unduplicated) 182 553.000000 40207.5800 72.7081
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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
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Total 6019.500000 326116.7100 54.1767
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Number of Children (Unduplicated) With at Least One Service 995
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Center 54
Flag Claims Units Chgs Paid
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R 84 81.500000 4352.0200 0.0000
U 0 0.000000 0.0000 0.0000
B 2300 2196.750000 114038.8200 0.0000
P 1393 1314.750000 72050.1900 71255.2700
D 200 176.500000 8295.8000 6233.1400
S 129 111.000000 4956.0000 0.0000
H 4 3.750000 206.9400 0.0000
T 0 0.000000 0.0000 0.0000
1813 1928.750000 112594.5600 0.0000
Other 296 206.500000 9622.3800 1625.9400
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Total 6219 6019.500000 326116.7100 79114.3500