CMS/EIP Fiscal Report Center: 55
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 568 2342.250000 105495.1400 45.0401
Subtotal (Total Children Is Unduplicated) 568 2342.250000 105495.1400 45.0401
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 36.000000 2915.2800 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 7 13.000000 778.9600 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 90 184.000000 14900.3200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 647.8400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 56.000000 4534.8800 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 971.7600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 46.000000 3725.0800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 46.000000 2756.3200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 10.000000 581.1000 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 522.9900 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 146 442.000000 33764.6500 76.3906
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 190 972.250000 52501.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 15 64.000000 3456.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 191.000000 15532.1200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 51 337.250000 21961.7200 65.1200
OCCT-97530HMGT-OT SESSION BY OT ASST 1 4.000000 260.4800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 16 74.000000 6017.6800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 20 94.000000 6121.2800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 93 479.500000 38992.9400 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 18.000000 1463.7600 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 3 14.000000 1138.4800 81.3200
Subtotal (Total Children Is Unduplicated) 393 2248.000000 147445.9600 65.5898
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Total 5032.250000 286705.7500 56.9737
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Number of Children (Unduplicated) With at Least One Service 588
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Center 55
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 2879 2620.750000 129081.3900 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2355 2411.500000 157624.3600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5234 5032.250000 286705.7500 0.0000