CMS/EIP Fiscal Report Center: 05
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 484 225.000000 8370.0000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 152 121.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 479 1210.000000 45012.0000 37.2000
Subtotal (Total Children Is Unduplicated) 741 1556.000000 53382.0000 34.3072
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 34.000000 2550.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 14 25.000000 1875.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 30.000000 2250.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 28.000000 1554.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 19 34.500000 1914.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 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 2 2.000000 62.8200 31.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 74 210.000000 13878.2400 66.0869
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 7.000000 966.3900 138.0557
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 63 65.000000 3250.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 27 22.000000 1100.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 28 26.250000 1287.5000 49.0476
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 23 55.000000 2750.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 11 3.750000 93.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 15 15.250000 762.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 19 54.000000 2700.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 16.000000 800.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 4 6.750000 337.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 15.250000 762.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 9 8.500000 425.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.000000 25.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 8.000000 200.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 7 17.500000 875.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 147 657.000000 32812.0000 49.9422
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 33.000000 1650.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 403 2722.000000 40782.0000 14.9824
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 233 1046.000000 12552.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 66.500000 4091.3400 61.5239
PHY-97110-PT SESSION BY LICENSED PT 21 70.000000 4758.3000 67.9757
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 47.500000 3341.1900 70.3408
TRAV-TRAVS-Travel by mile 504 50273.00000 22377.6300 0.4451
Subtotal (Total Children Is Unduplicated) 612 55239.25000 138821.5600 2.5131
-----------------------------------------------------------------------------------------------------------------------
Total 57005.250000 206081.8000 3.6151
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 918
-----------------------------------------------------------------------------------------------------------------------
Center 05
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 8284 55408.250000 151695.1700 151695.1700
D 55 36.750000 1367.1000 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
3075 1560.250000 53019.5300 1004.6300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11414 57005.250000 206081.8000 152699.8000