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: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 898 3204.500000 119207.4000 37.2000
Subtotal (Total Children Is Unduplicated) 1290 4133.500000 151563.8500 36.6672
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 103.885733 7791.4300 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 12 24.000000 1800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 31.738933 2380.4200 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 45.787866 3434.0900 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 88.000000 4884.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 22.000000 1229.8400 55.9018
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) 157 410.265867 27483.2300 66.9888
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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 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 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 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 2 140.000000 62.3000 0.4450
Subtotal (Total Children Is Unduplicated) 785 9478.707888 269156.7500 28.3959
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Total 14022.473755 448203.8300 31.9632
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Number of Children (Unduplicated) With at Least One Service 1418
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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 1 0.750000 27.9000 27.9000
P 9370 9411.589377 270328.0600 270328.0600
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
6059 4610.134378 177847.8700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15430 14022.473755 448203.8300 270355.9600