CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2024 ending 12/31/2024 Date of Report:03/31/2025 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 298 216.750000 8063.1000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 9 54.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 819 1699.250000 63081.9000 37.1234
Subtotal (Total Children Is Unduplicated) 963 1970.000000 71145.0000 36.1142
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
EXIT-EXIT-COS Exit 4 4.000000 187.5000 46.8750
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 485.8800 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.000000 599.2000 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 60.500000 4849.2900 80.1536
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 41 75.500000 6113.9900 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 77 155.500000 9317.5600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 299.6000 59.9200
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 283.4300 80.9800
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 15.000000 871.6500 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 116.2200 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 155 351.000000 24111.2100 68.6929
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 93 90.750000 4358.3000 48.0253
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 89 87.250000 3964.5400 45.4389
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 3.500000 87.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 7.000000 350.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 33 48.000000 2400.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 20 31.000000 1550.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 24 34.000000 1700.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 67.500000 3375.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 14 22.000000 1100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 231 1209.500000 65205.0000 53.9107
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 30 82.000000 4428.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 305 1611.000000 24165.0000 15.0000
INTR-T1013-INTERPRETER 15 49.500000 3535.0000 71.4141
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 338 1734.000000 20784.0000 11.9862
OCCT-97530-OT SESSION BY LICENSED OT 16 57.000000 4583.3500 80.4096
OCCT-97530GOGT-OT SESSION BY LICENSED OT 3 5.000000 406.6000 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 1 6.000000 487.9200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 20 93.500000 7603.4200 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 3 3.000000 243.9600 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 162.000000 13140.1900 81.1123
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
TRAV-TRAVS-Travel by mile 488 49859.00000 22167.7700 0.4446
Subtotal (Total Children Is Unduplicated) 673 55266.50000 185816.8700 3.3622
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Total 57587.500000 281073.0800 4.8808
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Number of Children (Unduplicated) With at Least One Service 1272
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Center 03
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 8131 54783.750000 195130.1700 195130.1700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 76 457.000000 1940.6300 1940.6300
T 0 0.000000 0.0000 0.0000
3177 2346.750000 84002.2800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11384 57587.500000 281073.0800 197070.8000