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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 645 2613.750000 117789.1400 45.0652
Subtotal (Total Children Is Unduplicated) 645 2613.750000 117789.1400 45.0652
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 42.000000 3401.1600 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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 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 154 314.000000 25427.7200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 18.000000 1457.6400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 49 98.000000 7936.0400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 9 18.000000 1457.6400 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 40 80.000000 6478.4000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 32 64.000000 3834.8800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 479.3600 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) 220 694.000000 53708.2900 77.3895
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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 5555.750000 318943.3900 57.4078
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Number of Children (Unduplicated) With at Least One Service 667
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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 3082 3048.250000 154192.7900 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
2400 2507.500000 164750.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5482 5555.750000 318943.3900 0.0000