CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2024 ending 06/30/2024 Date of Report:04/12/2025 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 1067 1483.500000 55112.8000 37.1505
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 60 42.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 628 1400.000000 52052.1000 37.1801
Subtotal (Total Children Is Unduplicated) 1263 2926.000000 107164.9000 36.6251
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 0.000000 0.0000 0.0000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 3.000000 26.4300 8.8100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 4.000000 106.6800 26.6700
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 13.8100 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
EXIT-EXIT-COS Exit 2 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 15.000000 1275.0000 85.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 18.000000 1350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 6.500000 487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 37 66.500000 3690.7500 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 4 8.000000 600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 65 163.500000 10408.2100 63.6588
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 4.000000 311.7700 77.9425
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 24 19.250000 962.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 24 26.750000 1371.9600 51.2882
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 0.500000 12.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 13 10.750000 537.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 106 87.750000 4375.0000 49.8575
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 44 57.750000 2887.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 85 75.500000 3800.0000 50.3311
CONOP-CONOP-CONSULT, OT, PHONE 8 5.000000 125.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 40 58.000000 2900.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 152 90.000000 4525.0000 50.2778
CONPP-CONPP-CONSULT, PT, PHONE 19 9.750000 243.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 63 76.500000 3825.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 154 116.250000 5800.0000 49.8925
CONSP-CONSP-CONSULT, SLP, PHONE 12 6.500000 187.5000 28.8462
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 486 1440.250000 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 96 542.000000 27100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 33 56.750000 2837.5000 50.0000
EPIC-99601-Early Steps Professional Development Fee 602 3091.000000 46365.0000 15.0000
INTR-T1013-INTERPRETER 3 3.500000 105.9800 30.2800
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 291 1320.000000 15840.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 49.807400 3584.1400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 3.500000 251.8600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 5 7.250000 521.7100 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 5.000000 359.8000 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 71.000000 5109.1600 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 6 21.000000 1511.1600 71.9600
TRAV-TRAVS-Travel by mile 380 31518.00000 14020.8400 0.4449
Subtotal (Total Children Is Unduplicated) 828 38777.30740 149691.0500 3.8603
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Total 41866.807400 267264.1600 6.3837
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Number of Children (Unduplicated) With at Least One Service 1482
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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 356 279.250000 11824.7800 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 5065 34397.557400 78991.5200 51748.2500
10093 7185.750000 176289.7600 0.0000
Other 5 4.250000 158.1000 0.0000
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Total 15519 41866.807400 267264.1600 51748.2500