CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2025 ending 03/31/2025 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 172 67.500000 2511.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1253 2787.500000 104615.7000 37.5303
Subtotal (Total Children Is Unduplicated) 1349 2855.000000 107126.7000 37.5225
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 7 7.000000 339.5000 48.5000
EXIT-EXIT-COS Exit 56 63.000000 3175.0000 50.3968
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 119.8600 59.9300
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 242.9400 60.7350
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 20.500000 1228.3600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 404.9000 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 121.4700 80.9800
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 7.000000 406.7700 58.1100
Subtotal (Total Children Is Unduplicated) 92 124.500000 6959.9600 55.9033
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 114 121.000000 5978.0000 49.4050
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 84 104.000000 5212.5000 50.1202
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 39 41.750000 1075.0000 25.7485
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 94 138.500000 6925.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 123 288.000000 11400.0000 39.5833
CONIP-CONIP-CONSULT, ITDS PHONE 10 11.750000 293.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 12 12.000000 600.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 60 116.750000 5837.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 3.000000 75.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 36 41.250000 2062.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 35 49.000000 2450.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 69 94.000000 4700.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 57 103.000000 5150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 6 4.500000 137.5000 30.5556
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 54.0000 54.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 178 797.500000 43065.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 28 70.750000 3817.5000 53.9576
EPIC-99601-Early Steps Professional Development Fee 285 1604.000000 24060.0000 15.0000
INTR-T1013-INTERPRETER 106 230.000000 12862.3500 55.9233
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1271 8057.000000 96684.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 17.000000 1382.4400 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
PHY-97110-PT SESSION BY LICENSED PT 16 46.500000 3738.4600 80.3970
PHY-97110GT-PT SESSION BY LICENSED PT 2 8.000000 650.5600 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 56.250000 4574.2500 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 325.2800 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 5.000000 325.6000 65.1200
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 1.000000 65.1200 65.1200
TRAV-TRAVS-Travel by mile 338 22561.00000 10043.1500 0.4452
Subtotal (Total Children Is Unduplicated) 1621 34590.50000 253675.7800 7.3337
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Total 37570.000000 367762.4400 9.7887
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Number of Children (Unduplicated) With at Least One Service 2425
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Center 01
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 11508 31605.250000 211230.7000 211218.7000
D 214 590.500000 4924.7900 0.0000
S 2 1.500000 55.8000 0.0000
H 0 0.000000 0.0000 0.0000
T 2051 2514.750000 44236.3700 44501.6500
4306 2858.000000 107314.7800 54.0000
Other 0 0.000000 0.0000 0.0000
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Total 18081 37570.000000 367762.4400 255774.3500