CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 Page: 1
List order: No List
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 446 376.500000 17177.3200 45.6237
TCM-T1017TL-TARGETED CASE MANAGEMENT 964 3493.250000 158638.8600 45.4130
Subtotal (Total Children Is Unduplicated) 983 3869.750000 175816.1800 45.4335
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 4 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 9.500000 769.3100 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 12 13.500000 1093.2300 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 5.500000 445.3900 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 364.4100 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 11 15.000000 898.8000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 15 22.000000 1318.2400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 9 19.500000 1579.1100 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 7 9.500000 769.3100 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 50.000000 4049.0000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 139 160.000000 12956.8000 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 19.500000 1513.4400 77.6123
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 75 84.000000 6802.3200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 50.500000 3003.2400 59.4701
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 189 277.500000 16627.8000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 85.500000 6880.0100 80.4680
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 103 150.500000 12187.4900 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 32 32.000000 3466.7500 108.3359
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 295.8700 73.9675
OCTH-97165-OT EVAL LOW COMPLEXITY 7 7.000000 366.4400 52.3486
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 4 4.000000 232.4400 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 5 5.000000 290.5500 58.1100
Subtotal (Total Children Is Unduplicated) 319 1037.500000 76400.5000 73.6390
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 25 52.750000 2637.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 87 566.000000 15282.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 919 6320.000000 341280.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 10 48.000000 2592.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 781 5383.000000 80745.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 198 1083.000000 12996.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 51.250000 3777.6900 73.7110
OCCT-97530HM-OT SESSION BY OT ASST 38 154.500000 10061.0400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 39 80.500000 6546.2600 81.3200
PHY-97110HM-PT SESSION BY PT ASST 56 162.500000 10582.0000 65.1200
PHY-97110TLHM-PT SESSION BY PT ASST 1 6.000000 390.7200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 66 215.500000 17524.4600 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 36.500000 2376.8800 65.1200
Subtotal (Total Children Is Unduplicated) 1041 14159.50000 506791.5500 35.7916
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Total 19066.750000 759008.2300 39.8080
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Number of Children (Unduplicated) With at Least One Service 1570
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Center 04
Flag Claims Units Chgs Paid
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R 113 204.250000 9344.3800 0.0000
U 0 0.000000 0.0000 0.0000
B 993 1643.250000 77901.9500 0.0000
P 8703 8998.000000 227654.3300 225494.7600
D 11 20.000000 1036.4100 0.0000
S 0 0.000000 0.0000 0.0000
H 4912 4911.750000 266572.7200 0.0000
T 0 0.000000 0.0000 0.0000
3534 3262.000000 174711.6900 0.0000
Other 26 27.500000 1786.7500 15.0000
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Total 18292 19066.750000 759008.2300 225509.7600