CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 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 1008 1469.000000 54646.7000 37.1999
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 39 30.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 537 1235.750000 45951.3000 37.1849
Subtotal (Total Children Is Unduplicated) 1159 2735.250000 100598.0000 36.7784
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 4.000000 194.0000 48.5000
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 2 2.000000 31.6800 15.8400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 86.7600 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
EXIT-EXIT-COS Exit 3 4.000000 200.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 26 47.500000 2636.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
Subtotal (Total Children Is Unduplicated) 49 126.500000 7781.4800 61.5137
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 7.000000 829.4400 118.4914
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 16 10.250000 512.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 17 16.250000 812.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 3.250000 162.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 128 121.000000 6050.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 5 4.750000 118.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 34 49.750000 2487.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 107 102.000000 5125.0000 50.2451
CONPF-CONPF-CONSULT, PT, FACE TO FACE 40 79.500000 3975.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 145 83.500000 4175.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 25 11.000000 275.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 57 75.250000 3762.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 177 132.750000 6637.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 14 13.000000 325.0000 25.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 433 1512.250000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 86 398.750000 19937.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 27 50.500000 2525.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 542 3045.000000 45675.0000 15.0000
INTR-T1013-INTERPRETER 2 1.500000 47.5800 31.7200
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 226 1045.000000 12540.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 21.735690 1564.1000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 7 21.000000 1511.1600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 1.500000 107.9400 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 59.750000 4299.6100 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 215.8800 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 6 21.000000 1511.1600 71.9600
TRAV-TRAVS-Travel by mile 322 29767.00000 13241.5200 0.4448
Subtotal (Total Children Is Unduplicated) 747 36660.73569 138631.0600 3.7815
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Total 39522.485690 247010.5400 6.2499
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Number of Children (Unduplicated) With at Least One Service 1337
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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 335 242.500000 11028.0100 0.0000
S 1 0.250000 9.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 4325 32165.485690 64095.1300 62541.1000
9880 7114.250000 171878.1000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14541 39522.485690 247010.5400 62541.1000