CMS/EIP Fiscal Report Center: 06
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 835 461.250000 17177.1000 37.2403
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 16 9.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 889 2768.500000 102988.2000 37.2000
Subtotal (Total Children Is Unduplicated) 1325 3239.500000 120165.3000 37.0938
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 121 93.750000 4643.7500 49.5333
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 134 137.750000 7608.1600 55.2317
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 80 91.750000 4325.0000 47.1390
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 91 114.750000 5512.5000 48.0392
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 59 54.750000 1337.5000 24.4292
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 7 11.000000 550.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 6 7.500000 375.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 3.500000 87.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 6.500000 325.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 7 8.000000 400.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.500000 62.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 6.000000 300.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 0.500000 25.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 405 3223.500000 159129.0000 49.3653
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 92 396.500000 19212.5000 48.4552
EPIC-99601-Early Steps Professional Development Fee 509 4062.000000 60375.0000 14.8634
INTR-T1013-INTERPRETER 42 342.250000 21595.0000 63.0972
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 496 3755.000000 44907.0000 11.9593
OCCT-97530-OT SESSION BY LICENSED OT 3 18.500000 899.5000 48.6216
OCCT-97530GT-OT SESSION BY LICENSED OT 1 0.500000 35.9800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 1 7.000000 172.8000 24.6857
OCCT-97530HMGT-OT SESSION BY OT ASST 2 9.000000 518.4000 57.6000
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 100.7300 50.3650
PHY-97110HMGT-PT SESSION BY PT ASST 1 6.500000 374.1400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 67.500000 4871.3400 72.1680
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 19.750000 1465.6700 74.2111
Subtotal (Total Children Is Unduplicated) 1071 12219.75000 327032.0600 26.7626
-----------------------------------------------------------------------------------------------------------------------
Total 15597.000000 454805.5200 29.1598
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1774
-----------------------------------------------------------------------------------------------------------------------
Center 06
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 12075 12238.000000 327313.5800 327313.5800
D 0 0.000000 0.0000 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
5075 3260.250000 123818.4400 0.0000
Other 192 98.750000 3673.5000 0.0000
---------------------------------------------------------
Total 17342 15597.000000 454805.5200 327313.5800