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
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 369 255.000000 9486.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 835 1883.000000 70047.6000 37.2000
Subtotal (Total Children Is Unduplicated) 999 2138.000000 79533.6000 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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 50.000000 3750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 50.000000 3750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.500000 443.6200 68.2492
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 75 145.500000 8075.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 450.6300 56.3288
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 4.000000 205.6400 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 10.000000 514.1000 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 411.2800 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4400 51.4400
Subtotal (Total Children Is Unduplicated) 146 306.250000 18940.1000 61.8452
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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 77.500000 3882.0000 50.0903
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 20 91.000000 6548.3600 71.9600
OCCT-97530GOGT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 8.000000 575.6800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 21 95.250000 6854.1900 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 8 9.000000 647.6400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 153.750000 11073.2100 72.0209
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 2.750000 197.8900 71.9600
TRAV-TRAVS-Travel by mile 502 55361.00000 24624.5400 0.4448
Subtotal (Total Children Is Unduplicated) 691 61375.75000 197786.3900 3.2225
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Total 63820.000000 296260.0900 4.6421
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Number of Children (Unduplicated) With at Least One Service 1318
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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 9070 61448.250000 208372.0600 208372.0600
D 0 0.000000 0.0000 0.0000
S 10 24.000000 198.7600 198.7600
H 11 33.000000 358.6800 358.6800
T 1504 1073.000000 40049.2100 40049.2100
1863 1241.750000 47281.3800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 12458 63820.000000 296260.0900 248978.7100