CMS/EIP Fiscal Report Center: 54
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 717 493.000000 18339.6000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 124 88.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 820 2530.750000 94078.6000 37.1742
Subtotal (Total Children Is Unduplicated) 1257 3112.000000 112418.2000 36.1241
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 17 18.000000 873.0000 48.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 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 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.500000 787.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 5.000000 375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 26 48.500000 3649.4600 75.2466
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 39.500000 2962.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 54.000000 2997.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 43 87.000000 4846.1800 55.7032
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 21.000000 1575.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 20.000000 1461.0000 73.0500
Subtotal (Total Children Is Unduplicated) 127 352.500000 23006.6400 65.2671
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 2 2.000000 84.8200 42.4100
ASST-ASST-ASSISTIVE TECHNOLOGY 31 79.000000 3960.3500 50.1310
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 92 88.000000 4400.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 179 183.750000 9187.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 54 61.250000 3062.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 187 91.250000 4562.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 84 106.500000 5325.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 297 152.250000 7612.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 38 41.500000 2040.0000 49.1566
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 116 43.250000 2162.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 54 65.000000 3250.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 190 86.250000 4312.5000 50.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 583 1765.500000 50.0000 0.0283
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 117 518.500000 25949.0000 50.0463
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 55 114.750000 5761.5000 50.2092
EPIC-99601-Early Steps Professional Development Fee 733 3366.000000 50487.0000 14.9991
INTR-T1013-INTERPRETER 4 5.750000 178.7400 31.0852
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 442 2100.000000 25200.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 90.000000 6476.4000 71.9600
OCCT-97530GO-OT SESSION BY LICENSED OT 5 6.000000 441.1200 73.5200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 7 15.000000 1079.4000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 1 4.000000 230.4000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 2 5.000000 359.8000 71.9600
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 25 127.250000 9156.9100 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 3 3.750000 269.8500 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 138.000000 9930.4800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 17.750000 1277.2900 71.9600
TRAV-TRAVS-Travel by mile 643 40997.00000 18238.8200 0.4449
Subtotal (Total Children Is Unduplicated) 1121 50277.25000 205248.4000 4.0823
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Total 53741.750000 340673.2400 6.3391
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Number of Children (Unduplicated) With at Least One Service 1655
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Center 54
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 264 198.250000 8169.3700 0.0000
S 26 35.500000 230.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 7350 45293.500000 116113.9100 115879.9400
10296 8187.000000 215093.5100 0.0000
Other 45 27.500000 1066.4500 0.0000
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Total 17981 53741.750000 340673.2400 115879.9400