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: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 599 271.500000 10099.8000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 217 172.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 558 1526.250000 56776.5000 37.2000
Subtotal (Total Children Is Unduplicated) 876 1970.500000 66876.3000 33.9387
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.000000 675.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 388.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 57.000000 4275.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 20 33.500000 2437.5000 72.7612
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 46.500000 3487.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 15.500000 1162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 45.500000 2503.0500 55.0121
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 43 73.000000 4051.5000 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) 116 336.000000 22031.7900 65.5708
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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 29 27.250000 1337.5000 49.0826
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 16 16.250000 812.5000 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 19 16.250000 812.5000 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 8 18.500000 925.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 150 672.000000 33562.0000 49.9435
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 33.000000 1650.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 425 2769.000000 41487.0000 14.9827
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 267 1085.000000 13020.0000 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 570 51907.00000 23104.5500 0.4451
Subtotal (Total Children Is Unduplicated) 682 56978.25000 141671.4800 2.4864
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Total 59284.750000 230579.5700 3.8894
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Number of Children (Unduplicated) With at Least One Service 1056
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Center 05
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 8564 57273.250000 162698.6400 162698.6400
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
3685 1974.750000 66513.8300 1004.6300
Other 0 0.000000 0.0000 0.0000
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Total 12304 59284.750000 230579.5700 163703.2700