CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 245 355.500000 16052.6800 45.1552
Subtotal (Total Children Is Unduplicated) 245 355.500000 16052.6800 45.1552
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 14 28.000000 1400.0000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 121.4700 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 6.500000 526.3700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 149.8000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 10.500000 629.1600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 30.000000 2429.4000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 47 65.500000 5304.1900 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 47.500000 3846.5500 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 53 89.000000 7207.2200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 78.000000 4673.7600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 130 179.500000 10755.6400 59.9200
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 25 25.000000 1338.7500 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 102.8700 34.2900
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 246 570.000000 38722.8700 67.9349
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 22 34.000000 1700.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 12 13.250000 331.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 12.000000 600.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 5.000000 135.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 182 719.808889 38869.6800 54.0000
EPIC-99601-Early Steps Professional Development Fee 428 2112.000000 31680.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 144 591.000000 7239.0000 12.2487
OCCT-97530-OT SESSION BY LICENSED OT 24 87.000000 7074.8400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 4 10.250000 667.4800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 60 286.000000 23257.5200 81.3200
PHY-97110HM-PT SESSION BY PT ASST 2 8.000000 520.9600 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 93 411.000000 33422.5200 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 325.2800 81.3200
TRAV-TRAVS-Travel by mile 94 4657.000000 2071.6600 0.4448
Subtotal (Total Children Is Unduplicated) 595 8955.308889 148145.1900 16.5427
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Total 9880.808889 202920.7400 20.5369
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Number of Children (Unduplicated) With at Least One Service 940
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Center 04
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 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
81 93.000000 5336.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 81 93.000000 5336.4200 0.0000
Center 07
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 57 57.000000 831.0000 831.0000
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
0 0.000000 0.0000 0.0000
Other 63 23.500000 1026.8400 0.0000
---------------------------------------------------------
Total 120 80.500000 1857.8400 831.0000
Center 09
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 2200 3954.000000 74959.6400 74959.6400
D 31 42.000000 1025.7800 0.0000
S 0 0.000000 0.0000 0.0000
H 384 567.000000 35123.7000 0.0000
T 2332 4759.750000 72147.1000 72147.1000
8 9.000000 427.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4955 9331.750000 183683.9800 147106.7400
Center 52
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 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
24 157.000000 703.8400 517.8400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24 157.000000 703.8400 517.8400
Center 55
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 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
30 28.058889 1793.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 28.058889 1793.5200 0.0000
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 0 0.000000 0.0000 0.0000
D 2 2.000000 100.0000 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
46 59.250000 3541.0000 0.0000
Other 116 129.250000 5904.1400 0.0000
---------------------------------------------------------
Total 164 190.500000 9545.1400 0.0000