CMS/EIP Fiscal Report Center: 57
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 699 2643.500000 120755.0800 45.6800
Subtotal (Total Children Is Unduplicated) 699 2643.500000 120755.0800 45.6800
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 24.000000 1943.5200 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 16 28.000000 1677.7600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 49.500000 4008.5100 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 148 259.000000 20973.8200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 9.500000 769.3100 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 20.000000 1619.6000 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 180 321.000000 19234.3200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.000000 719.0400 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 211 735.500000 51835.0600 70.4759
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 753 5763.000000 311163.0000 53.9932
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 20 61.500000 3321.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 69.500000 5651.7400 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 3 4.500000 293.0400 65.1200
PHY-97110HM-PT SESSION BY PT ASST 4 29.000000 1888.4800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 16.000000 1301.1200 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 37.000000 2409.4400 65.1200
Subtotal (Total Children Is Unduplicated) 773 5982.500000 326190.4600 54.5241
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Total 9361.500000 498780.6000 53.2800
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Number of Children (Unduplicated) With at Least One Service 1030
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Center 57
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1931 3124.250000 158437.8700 158437.8700
T 0 0.000000 0.0000 0.0000
6149 6237.250000 340342.7300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8080 9361.500000 498780.6000 158437.8700