CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 134 80.750000 3688.6600 45.6800
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 44.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 318 410.000000 18728.8000 45.6800
Subtotal (Total Children Is Unduplicated) 414 534.750000 22417.4600 41.9214
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-COS Exit 5 5.000000 250.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.000000 809.8000 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 3 6.000000 359.5200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 179.7600 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 566.8600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 24.000000 1943.5200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 39.500000 3198.7100 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 69.000000 4134.4800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 24.000000 1943.5200 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
SCREEN-T1023-SCREENING 3 3.000000 161.9400 53.9800
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) 93 204.500000 14447.1400 70.6462
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 53 38.250000 1937.5000 50.6536
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 11 10.250000 512.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.250000 6.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 13.000000 650.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 3 3.000000 150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 13 15.000000 750.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 7 7.000000 350.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 149 463.000000 25002.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 24.000000 1296.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 341 1105.000000 15647.0100 14.1602
INTR-T1013-INTERPRETER 9 23.000000 1837.5000 79.8913
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 174 549.000000 6588.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 23.000000 1870.3600 81.3200
PHY-97110-PT SESSION BY LICENSED PT 14 37.000000 3008.8400 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 72.000000 5855.0400 81.3200
TRAV-TRAVS-Travel by mile 467 28463.00000 12663.3300 0.4449
Subtotal (Total Children Is Unduplicated) 533 30847.75000 78224.3300 2.5358
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Total 31587.000000 115088.9300 3.6436
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Number of Children (Unduplicated) With at Least One Service 819
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Center 03
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4824 31587.000000 115088.9300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4824 31587.000000 115088.9300 0.0000