CMS/EIP Fiscal Report Center: 57
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 577 537.500000 19995.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 652 2708.250000 100746.9000 37.2000
Subtotal (Total Children Is Unduplicated) 1015 3245.750000 120741.9000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 5 12.500000 625.0000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 242.9400 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 2 3.500000 209.7200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 22.000000 1781.5600 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 242.9400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 33.000000 2672.3400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 283.4300 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 21.000000 1700.5800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 242.9400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 41 73.000000 4374.1600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 10.000000 599.2000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 242.9400 80.9800
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 174.3300 58.1100
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 11 11.000000 639.2100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 290.5500 58.1100
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 14.000000 813.5400 58.1100
Subtotal (Total Children Is Unduplicated) 86 231.500000 15646.0000 67.5853
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.000000 200.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 148 150.000000 7500.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 70 70.000000 3500.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 16 19.000000 950.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 275 276.000000 13800.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 143 143.000000 7150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 544 5383.000000 290682.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 38.000000 2052.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 1032 10124.00000 151860.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 554 4077.000000 48924.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 43.000000 3496.7600 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 1 2.000000 162.6400 81.3200
PHY-97110-PT SESSION BY LICENSED PT 3 10.000000 813.2000 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 4 24.500000 1992.3400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 13.000000 846.5600 65.1200
TRAV-TRAVS-Travel by mile 9 3097.000000 1378.1200 0.4450
Subtotal (Total Children Is Unduplicated) 1380 23474.50000 535357.6200 22.8059
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Total 26951.750000 671745.5200 24.9240
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Number of Children (Unduplicated) With at Least One Service 1738
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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 178 178.000000 4764.1100 0.0000
S 0 0.000000 0.0000 0.0000
H 4 7.500000 279.0000 279.0000
T 20367 23307.000000 532148.6800 532148.6800
3145 3459.250000 134553.7300 18.6000
Other 0 0.000000 0.0000 0.0000
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Total 23694 26951.750000 671745.5200 532446.2800