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
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 1072 870.000000 32356.4500 37.1913
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 66 59.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1385 6185.500000 230119.2000 37.2030
Subtotal (Total Children Is Unduplicated) 1426 7114.500000 262475.6500 36.8931
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 44 88.000000 6600.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 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 14 28.000000 2100.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 20 40.000000 2220.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 260 530.000000 39750.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 45 90.000000 6761.9600 75.1329
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 57 114.000000 8500.0000 74.5614
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 63 126.000000 9450.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 30.000000 2273.9200 75.7973
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 137 274.000000 15207.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 26 52.000000 2903.6800 55.8400
OCTF-97168-OT RE-EVAL EST PLAN CARE 19 18.999999 996.8900 52.4679
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 32 32.000000 1651.8200 51.6194
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 11 11.000000 565.5100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 9 9.000000 462.6900 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 25 25.000000 1285.2500 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 462 1531.999999 105221.5200 68.6825
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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 83.000000 2075.0000 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 391 3041.500000 152167.0000 50.0302
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 47.000000 2362.0000 50.2553
EPIC-99601-Early Steps Professional Development Fee 322 2432.000000 36480.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 463 3471.000000 41717.9600 12.0190
OCCT-97530-OT SESSION BY LICENSED OT 102 594.500009 42750.0500 71.9093
OCCT-97530HM-OT SESSION BY OT ASST 109 857.569841 49432.7200 57.6428
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 62 452.625087 28999.8800 64.0704
PHY-97110HM-PT SESSION BY PT ASST 61 458.868651 26420.0692 57.5765
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 249 1783.174663 128418.3000 72.0167
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 11 66.000000 4749.3600 71.9600
TRAV-TRAVS-Travel by mile 2 140.000000 62.3000 0.4450
Subtotal (Total Children Is Unduplicated) 829 13851.73825 533254.9092 38.4973
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Total 22498.238250 900952.0792 40.0455
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Number of Children (Unduplicated) With at Least One Service 1467
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Center 55
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 429 429.750000 20208.5000 46.5000
P 13164 13268.839377 446750.0200 446722.5800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 42 82.000000 6135.3300 0.0000
T 0 0.000000 0.0000 0.0000
10067 8717.648873 427858.2292 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 23702 22498.238250 900952.0792 446769.0800