CMS/EIP Fiscal Report Center: 52
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 612 333.250000 14433.2600 43.3106
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 360 1074.500000 48522.4000 45.1581
Subtotal (Total Children Is Unduplicated) 776 1408.250000 62955.6600 44.7049
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 647.8400 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 6 12.000000 719.0400 59.9200
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 30.000000 2429.4000 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 971.7600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 485.8800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 98.000000 5812.2400 59.3086
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
SCREEN-T1023-SCREENING 3 3.000000 161.9400 53.9800
Subtotal (Total Children Is Unduplicated) 69 177.000000 11740.7400 66.3319
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 28 26.500000 1325.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 34 41.750000 2087.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 22 15.750000 393.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 40 52.500000 2625.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 3 3.000000 150.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 23 26.750000 1337.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 25 60.000000 3000.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 20 23.000000 1150.0000 50.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 148 191.750000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 166.750000 9004.5000 54.0000
EPIC-99601-Early Steps Professional Development Fee 412 1800.000000 27000.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 279 1226.000000 14712.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 8.000000 650.5600 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 1 4.000000 325.2800 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 130.2400 65.1200
OCCT-97530TL-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
PHY-97110-PT SESSION BY LICENSED PT 5 17.000000 1382.4400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 130.2400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 11.000000 894.5200 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
TRAV-TRAVS-Travel by mile 347 24374.00000 10843.2200 0.4449
Subtotal (Total Children Is Unduplicated) 628 28059.75000 77685.8500 2.7686
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Total 29645.000000 152382.2500 5.1402
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Number of Children (Unduplicated) With at Least One Service 998
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Center 52
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 3 1.500000 68.5200 0.0000
H 0 0.000000 0.0000 0.0000
T 4964 27747.500000 72732.6700 71150.6720
2884 1883.750000 79021.4800 49.1200
Other 14 12.250000 559.5800 0.0000
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Total 7865 29645.000000 152382.2500 71199.7920