CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
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 369 255.000000 9486.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1347 3328.750000 123829.5000 37.2000
Subtotal (Total Children Is Unduplicated) 1405 3583.750000 133315.5000 37.2000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 5.000000 242.5000 48.5000
EXIT-EXIT-COS Exit 6 5.250000 262.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 425.6200 65.4800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.500000 617.1100 64.9589
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 250.0000 62.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 110 198.500000 13698.7000 69.0111
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.000000 79.6000 39.8000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 93 163.000000 11786.2100 72.3080
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 39.500000 2833.6200 71.7372
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 114 218.500000 12126.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 450.6300 56.3288
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 5.000000 257.0500 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 52.3300 26.1650
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 219.0400 54.7600
PSTH-97162-PT EVAL MODERATE COMPLEXITY 7 12.000000 571.9200 47.6600
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 17.000000 838.9700 49.3512
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4400 51.4400
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 8.000000 411.2800 51.4100
Subtotal (Total Children Is Unduplicated) 278 726.750000 46125.2700 63.4679
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 78 84.500000 4181.2500 49.4822
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 120 126.250000 6087.5000 48.2178
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.250000 31.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 4 4.000000 162.5000 40.6250
CONOF-CONOF-CONSULT, OT, FACE TO FACE 32 46.000000 2300.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 22 33.000000 1650.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 36 53.000000 2650.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 3 4.000000 200.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 52 77.000000 3850.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 19 28.500000 1425.0000 50.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 5 28.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 226 1326.250000 66614.4600 50.2277
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 40 80.500000 4032.0000 50.0870
EPIC-99601-Early Steps Professional Development Fee 314 1688.000000 24984.0000 14.8009
INTR-T1013-INTERPRETER 17 71.750000 5055.0000 70.4530
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 374 2004.000000 24048.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 151.750000 10438.3400 68.7864
OCCT-97530GOGT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 9.000000 647.6400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 47 216.000000 14558.0800 67.3985
PHY-97110GT-PT SESSION BY LICENSED PT 9 13.500000 926.4600 68.6267
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 79 390.750000 26347.9200 67.4291
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 4.750000 341.8100 71.9600
TRAV-TRAVS-Travel by mile 502 55361.00000 24624.5400 0.4448
Subtotal (Total Children Is Unduplicated) 698 61804.75000 225299.6700 3.6453
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Total 66115.250000 404740.4400 6.1217
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Number of Children (Unduplicated) With at Least One Service 1524
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Center 03
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 9711 62240.250000 259412.4600 259412.4600
D 0 0.000000 0.0000 0.0000
S 10 24.000000 198.7600 198.7600
H 12 34.000000 440.0000 440.0000
T 1504 1073.000000 40049.2100 40049.2100
4005 2744.000000 104640.0100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15242 66115.250000 404740.4400 300100.4300