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
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 442 212.500000 7886.4000 37.1125
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 19 14.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 358 1018.750000 37683.6000 36.9900
Subtotal (Total Children Is Unduplicated) 651 1246.000000 45570.0000 36.5730
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 17.500000 1312.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 60.000000 3330.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 41 108.500000 6612.7300 60.9468
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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 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 210.250000 10512.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 6.000000 300.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 377 2269.000000 34035.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 430 2146.000000 25752.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 11.000000 791.5600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 8.000000 575.6800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 115.1200 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 2 3.000000 215.8800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 13.000000 935.4800 71.9600
TRAV-TRAVS-Travel by mile 431 35205.00000 15661.7300 0.4449
Subtotal (Total Children Is Unduplicated) 773 40754.75000 112357.4500 2.7569
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Total 42109.250000 164540.1800 3.9075
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Number of Children (Unduplicated) With at Least One Service 970
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 10 10.750000 516.9800 0.0000
S 1 0.500000 18.6000 0.0000
H 0 0.000000 0.0000 0.0000
T 7279 40197.500000 104839.7500 102365.6900
2966 1900.500000 59164.8500 12.0000
Other 0 0.000000 0.0000 0.0000
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Total 10256 42109.250000 164540.1800 102377.6900