CMS/EIP Fiscal Report Center: 52
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 442 212.500000 7886.4000 37.1125
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 19 14.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 776 2124.250000 78566.4000 36.9855
Subtotal (Total Children Is Unduplicated) 877 2351.500000 86452.8000 36.7650
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 16.000000 888.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 135 277.000000 19871.6000 71.7386
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 12 23.000000 1725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 69 135.500000 10012.5000 73.8930
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 9.000000 675.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 63.000000 4500.3000 71.4333
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 7.500000 397.7000 53.0267
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 172 340.500000 18897.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 24.000000 1780.5000 74.1875
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SCREEN-T1023-SCREENING 20 21.000000 1050.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 12.000000 565.5100 47.1258
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 7 35.000000 1542.3000 44.0657
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 5 22.000000 1151.5700 52.3441
Subtotal (Total Children Is Unduplicated) 267 1058.500000 67992.0600 64.2344
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 61 57.500000 2875.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 52 53.500000 2675.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 25 18.500000 475.0000 25.6757
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 60 173.000000 8650.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 4 3.750000 187.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 38 49.750000 2487.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 28 93.250000 4662.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 14 22.000000 1100.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 1 0.250000 12.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 234 402.000000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 516 2588.250000 129449.0000 50.0141
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 31 158.000000 7900.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 377 2270.000000 34050.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 430 2150.000000 25800.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 52 231.000000 15624.6800 67.6393
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 15 61.000000 4389.5600 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 8 28.500000 2050.8600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 46 216.250000 14280.4400 66.0367
PHY-97110HM-PT SESSION BY PT ASST 12 64.000000 3683.8400 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 35 141.750000 10200.3300 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 9 44.000000 2532.6400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 77 385.500000 24575.2500 63.7490
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 41 224.000000 16118.3000 71.9567
TRAV-TRAVS-Travel by mile 437 35400.00000 15748.4600 0.4449
Subtotal (Total Children Is Unduplicated) 776 44847.75000 330131.7400 7.3612
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Total 48257.750000 484576.6000 10.0414
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Number of Children (Unduplicated) With at Least One Service 1035
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Center 52
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 66 72.500000 3336.4000 0.0000
P 2707 2703.250000 132883.0500 133508.9500
D 142 160.500000 10799.1200 15.0000
S 30 37.250000 1588.4600 110.0000
H 10 15.000000 1109.8000 0.0000
T 8655 41674.000000 187063.3000 176143.4700
4331 3541.500000 144751.1200 211.6000
Other 45 53.750000 3045.3500 2830.2500
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Total 15986 48257.750000 484576.6000 312819.2700