CMS/EIP Fiscal Report Center: 53
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 1040 1390.750000 59701.4400 42.9275
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 77 58.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 496 1093.750000 47386.1000 43.3244
Subtotal (Total Children Is Unduplicated) 1184 2543.000000 107087.5400 42.1107
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 3 4.000000 194.0000 48.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.9200 7.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 49.5900 49.5900
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 15.1900 15.1900
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 0.500000 29.9600 59.9200
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 16.000000 1295.6800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 688.3300 72.4558
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 526.3700 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 16.000000 1295.6800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 364.4100 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 48.000000 2876.1600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 18 31.500000 1887.4800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 61 151.000000 10069.9700 66.6885
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 6.000000 421.9400 70.3233
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 11 8.250000 412.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 14 8.750000 437.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 5.500000 275.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 109 70.000000 3500.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 34 21.000000 1050.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 12 9.000000 450.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 150 90.250000 4512.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 20 7.750000 193.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 11 8.500000 412.5000 48.5294
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 143 108.250000 5412.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 1.750000 43.7500 25.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 459 1200.750000 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 133 508.000000 27432.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 22 30.000000 1620.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 665 2789.000000 41850.0000 15.0054
INTR-T1013-INTERPRETER 2 3.000000 150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 226 760.000000 9120.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 26.000000 2114.3200 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 4 13.000000 1057.1600 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
PHY-97110-PT SESSION BY LICENSED PT 14 58.000000 4716.5600 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.500000 40.6600 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 62.000000 5041.8400 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 7.500000 609.9000 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 243.9600 81.3200
TRAV-TRAVS-Travel by mile 436 21748.00000 9674.5900 0.4448
Subtotal (Total Children Is Unduplicated) 868 27562.75000 121293.2100 4.4006
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Total 30256.750000 238450.7200 7.8809
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Number of Children (Unduplicated) With at Least One Service 1437
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Center 53
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 75 64.250000 4221.5200 0.0000
S 8 8.000000 493.0100 0.0000
H 0 0.000000 0.0000 0.0000
T 1153 7115.750000 20828.4300 19531.5500
11551 23052.250000 211820.4700 130.2000
Other 27 16.500000 1087.2900 0.0000
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Total 12814 30256.750000 238450.7200 19661.7500