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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 485.8800 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 2 4.000000 323.9200 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 69 140.000000 11337.2000 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 24 48.000000 3887.0400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 485.8800 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 3.186027 185.1400 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 89 231.186027 18514.9800 80.0869
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 12.000000 648.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 73.213478 5953.7200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 18 87.739869 5713.6200 65.1200
OCCT-97530HMGT-OT SESSION BY OT ASST 2 6.095209 396.9200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 18 68.042794 5533.2400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 12 62.654484 4096.3400 65.3798
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 87 358.873954 29183.6300 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 10.000000 813.2000 81.3200
Subtotal (Total Children Is Unduplicated) 141 678.619788 52338.6700 77.1252
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Total 909.805815 70853.6500 77.8778
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Number of Children (Unduplicated) With at Least One Service 214
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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 0 0.000000 0.0000 0.0000
P 187 185.250000 14462.1800 14462.1800
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 141 138.750000 10263.8400 10263.8400
523 585.805815 46127.6300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 851 909.805815 70853.6500 24726.0200