CMS/EIP Fiscal Report Center: 57
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 623 574.500000 21362.1000 37.1838
TCM-T1017TL-TARGETED CASE MANAGEMENT 648 2711.000000 101351.4000 37.3852
Subtotal (Total Children Is Unduplicated) 1033 3285.500000 122713.5000 37.3500
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 2 7.000000 350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 388.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 28.500000 2137.5000 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 18 29.000000 2175.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 19.000000 1425.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 6.500000 487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 76.000000 4218.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 486.0000 69.4286
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 462.6900 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 5 5.000000 257.0500 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 79 232.500000 14756.1800 63.4674
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 2757.7200 2757.7200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 8.750000 437.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 200 204.000000 10200.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 18 19.000000 950.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 10 11.000000 550.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 15 17.000000 850.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 378 381.000000 19050.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 24 24.000000 1200.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 569 5328.000000 265232.0000 49.7808
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 16 45.000000 2250.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 985 9594.000000 143862.0000 14.9950
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 589 4722.000000 56664.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 53.500000 3849.8600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 3.000000 172.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 5 16.750000 1205.3300 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 6 29.500000 2122.8200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 6 25.000000 1439.0000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 22.500000 1619.1000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 359.8000 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 11 25.500000 1468.8000 57.6000
TRAV-TRAVS-Travel by mile 5 2516.000000 1119.6100 0.4450
Subtotal (Total Children Is Unduplicated) 1474 23053.50000 517460.3400 22.4461
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Total 26571.500000 654930.0200 24.6478
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Number of Children (Unduplicated) With at Least One Service 1770
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Center 57
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 203 203.000000 5980.1600 0.0000
S 0 0.000000 0.0000 0.0000
H 5 4.000000 2869.3200 2869.3200
T 20528 22869.500000 509779.6400 509779.6400
3305 3495.000000 136300.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 24041 26571.500000 654930.0200 512648.9600