CMS/EIP Fiscal Report Center: 54
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 658 438.750000 16312.2000 37.1788
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 96 74.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 823 2241.250000 83207.1000 37.1253
Subtotal (Total Children Is Unduplicated) 1201 2754.500000 99519.3000 36.1297
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 116.8300 116.8300
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 7 8.000000 388.0000 48.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 16.1500 16.1500
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.9200 7.9200
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 31.8100 31.8100
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 8.000000 647.8400 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 239.6800 59.9200
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 18.000000 1445.6800 80.3156
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 526.3700 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 20.500000 1660.0900 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 40.500000 3279.6900 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 809.8000 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 13 28.000000 2267.4400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 50.500000 3025.9600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 51 100.500000 6148.3200 61.1773
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 20.000000 1607.6400 80.3820
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 13.500000 1093.2300 80.9800
Subtotal (Total Children Is Unduplicated) 115 337.000000 23691.8700 70.3023
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 1 1.000000 47.9400 47.9400
ASST-ASST-ASSISTIVE TECHNOLOGY 24 41.000000 4092.9300 99.8276
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 77 72.250000 3589.5000 49.6817
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 192 190.500000 9537.5000 50.0656
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 44 45.000000 2237.5000 49.7222
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 183 87.000000 4387.5000 50.4310
CONOF-CONOF-CONSULT, OT, FACE TO FACE 44 39.750000 2043.8200 51.4169
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 277 128.500000 6431.3200 50.0492
CONPF-CONPF-CONSULT, PT, FACE TO FACE 39 38.000000 1900.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 114 38.750000 1950.0000 50.3226
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 65 71.250000 3562.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 190 79.750000 3990.6600 50.0396
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 563 1655.000000 268.9600 0.1625
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 27.0000 27.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 121 486.000000 26228.0000 53.9671
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 58 140.500000 7587.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 754 3236.000000 48774.9600 15.0726
INTR-T1013-INTERPRETER 2 5.500000 217.1600 39.4836
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 445 1870.000000 22452.0000 12.0064
OCCT-97530-OT SESSION BY LICENSED OT 15 75.000000 6042.8400 80.5712
OCCT-97530GO-OT SESSION BY LICENSED OT 17 58.000000 4675.9000 80.6190
OCCT-97530GOGT-OT SESSION BY LICENSED OT 9 14.250000 1158.8100 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.000000 243.9600 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 6 27.000000 1735.6800 64.2844
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 130.2400 65.1200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
PHY-97110-PT SESSION BY LICENSED PT 22 87.500000 7026.5800 80.3038
PHY-97110GT-PT SESSION BY LICENSED PT 3 5.000000 397.2400 79.4480
SENS-V5264-EARMOLD 1 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 131.750000 10453.2900 79.3419
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 9.750000 792.8700 81.3200
TRAV-TRAVS-Travel by mile 674 37530.00000 16695.0500 0.4448
Subtotal (Total Children Is Unduplicated) 1130 46178.00000 199077.6100 4.3111
-----------------------------------------------------------------------------------------------------------------------
Total 49269.500000 322288.7800 6.5413
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1650
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 280 194.250000 8379.5700 0.0000
S 32 38.250000 421.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 6850 41537.250000 113854.4900 113854.4900
9464 7468.000000 198373.2400 0.0000
Other 47 31.750000 1259.9800 0.0000
---------------------------------------------------------
Total 16673 49269.500000 322288.7800 113854.4900