CMS/EIP Fiscal Report Center: 55
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 1011 804.750000 29936.7000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 107 71.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 828 2779.250000 103388.1000 37.2000
Subtotal (Total Children Is Unduplicated) 1253 3655.500000 133324.8000 36.4724
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 14.000000 1133.7200 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 10.000000 809.8000 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 11 22.000000 1318.2400 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 119.000000 9636.6200 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 12 24.000000 1943.5200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 38.000000 3077.2400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 20.000000 1619.6000 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 34 68.000000 5506.6400 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 109.000000 6531.2800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 599.2000 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 8.804509 511.6300 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 6.061607 352.2400 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 4.654276 270.4600 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 5.924626 344.2800 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 6.509895 378.2900 58.1100
Subtotal (Total Children Is Unduplicated) 177 474.954913 34696.5900 73.0524
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 242.8000 121.4000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 9.500000 475.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 2 2.000000 100.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 111 111.500000 5575.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 4 4.000000 200.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 82 74.500000 1862.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 29 57.000000 2850.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 27 91.000000 2275.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 106 106.000000 5300.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 4 4.000000 200.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 84 76.500000 1912.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 176 1133.750000 61222.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 33.750000 1822.5000 54.0000
EPIC-99601-Early Steps Professional Development Fee 336 2445.000000 36675.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 404 2805.000000 33660.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 32 174.728112 14208.8900 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 25 161.759056 10512.0900 64.9861
PHY-97110-PT SESSION BY LICENSED PT 25 110.240162 8964.7300 81.3200
PHY-97110HM-PT SESSION BY PT ASST 17 90.361479 5884.3400 65.1200
PHY-97110HMGT-PT SESSION BY PT ASST 1 0.750000 48.8400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 93 457.914046 37237.5700 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 12.000000 975.8400 81.3200
Subtotal (Total Children Is Unduplicated) 749 7964.752855 232242.6000 29.1588
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Total 12095.207768 400263.9900 33.0928
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Number of Children (Unduplicated) With at Least One Service 1379
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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 0 0.000000 0.0000 0.0000
P 8153 8033.332585 242001.2200 242017.1200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 119.8400 0.0000
T 10 9.125183 480.4800 480.4800
5300 4050.750000 157662.4500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 13464 12095.207768 400263.9900 242497.6000