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: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 4 8.000000 647.8400 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.000000 485.8800 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 13.500000 808.9200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 209.7200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 45 84.000000 6802.3200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 77.500000 6275.9500 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.500000 850.2900 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 79 146.500000 8778.2800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 174.3300 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 174.3300 58.1100
Subtotal (Total Children Is Unduplicated) 107 377.000000 26773.2100 71.0165
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 85.000000 4590.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 51.000001 4147.3200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 3 12.000000 975.8400 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 162.6400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 2 14.000000 911.6800 65.1200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 195.3600 65.1200
Subtotal (Total Children Is Unduplicated) 25 167.000001 10982.8400 65.7655
-----------------------------------------------------------------------------------------------------------------------
Total 544.000001 37756.0500 69.4045
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 131
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 12 10.329440 797.1900 862.8700
D 3 3.000000 243.9600 0.0000
S 0 0.000000 0.0000 0.0000
H 182 334.000000 24035.7400 24035.7400
T 38 38.000000 2610.9600 2610.9600
158 158.670561 10068.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 393 544.000001 37756.0500 27509.5700