CMS/EIP Fiscal Report Center: 55
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 938 769.250000 28608.5500 37.1902
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 64 56.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 746 2657.750000 98868.3000 37.2000
Subtotal (Total Children Is Unduplicated) 1106 3483.000000 127476.8500 36.5997
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 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 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 69.885733 5241.4300 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 15.836800 1187.7600 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 33.885733 2541.4300 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 24 48.000000 2664.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 16.000000 896.8400 56.0525
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 5.099980 262.1900 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 1.092005 56.1400 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 11.428516 587.5400 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 4.989302 256.5000 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 2.243532 115.3400 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 565.5100 51.4100
Subtotal (Total Children Is Unduplicated) 113 284.461601 18983.9100 66.7363
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 14 15.250000 762.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 2 1.500000 75.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 108 104.500000 5225.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 4 4.000000 200.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 78 82.000000 2050.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 31 52.000000 2600.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 24 61.000000 1525.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 100 97.000000 4825.0000 49.7423
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 2 2.000000 100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 77 82.500000 2062.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 173 1378.750000 68945.5000 50.0058
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 26.000000 1308.0000 50.3077
EPIC-99601-Early Steps Professional Development Fee 321 2431.000000 36465.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 463 3471.000000 41717.9600 12.0190
OCCT-97530-OT SESSION BY LICENSED OT 47 264.975599 19050.0700 71.8937
OCCT-97530HM-OT SESSION BY OT ASST 39 215.802427 12430.2200 57.6000
PHY-97110-PT SESSION BY LICENSED PT 26 205.346977 11206.3200 54.5726
PHY-97110HM-PT SESSION BY PT ASST 21 140.149229 8030.4500 57.2993
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 114 701.183656 50457.1800 71.9600
TRAV-TRAVS-Travel by mile 1 70.000000 31.1500 0.4450
Subtotal (Total Children Is Unduplicated) 784 9407.707888 269110.6000 28.6053
-----------------------------------------------------------------------------------------------------------------------
Total 13175.169489 415571.3600 31.5420
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1234
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.750000 27.9000 27.9000
P 9331 9266.785111 265058.5900 265058.5900
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
5296 3907.634378 150484.8700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14628 13175.169489 415571.3600 265086.4900