CMS/EIP Fiscal Report Center: 05
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 584 264.500000 9858.0000 37.2703
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 232 206.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 512 1304.750000 48508.8000 37.1786
Subtotal (Total Children Is Unduplicated) 842 1775.500000 58366.8000 32.8734
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.000000 809.8000 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.000000 566.8600 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 5.000000 404.9000 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 9 9.500000 629.1600 66.2274
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.500000 808.9200 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 50.000000 4049.0000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 23 39.500000 3198.7100 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 16.500000 1336.1700 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 23.500000 1903.0300 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 9.000000 728.8200 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 68.500000 4104.5200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 38 68.000000 4074.5600 59.9200
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 106.2200 53.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 174.3300 58.1100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 3.000000 174.3300 58.1100
Subtotal (Total Children Is Unduplicated) 115 333.000000 23428.4900 70.3558
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 10.000000 797.1100 79.7110
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 83 85.000000 4250.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 22 20.750000 1037.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 50 73.500000 3650.0000 49.6599
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 8 12.750000 637.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 6.500000 162.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 13 12.250000 612.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 29 66.000000 3300.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 9 8.500000 425.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 3 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 19 17.000000 850.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 22 21.750000 1087.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.250000 31.2500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 6.000000 162.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 133 604.000000 32616.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 13 19.000000 1026.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 458 2353.000000 35283.0000 14.9949
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 217 747.000000 8964.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 84.000000 6720.8800 80.0105
OCCT-97530GT-OT SESSION BY LICENSED OT 1 8.000000 650.5600 81.3200
PHY-97110-PT SESSION BY LICENSED PT 29 39.250000 3024.1900 77.0494
PHY-97110GT-PT SESSION BY LICENSED PT 1 7.000000 569.2400 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 23.000000 1827.0500 79.4370
TRAV-TRAVS-Travel by mile 528 43514.00000 19358.4100 0.4449
Subtotal (Total Children Is Unduplicated) 646 47743.25000 127185.9400 2.6640
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Total 49851.750000 208981.2300 4.1921
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Number of Children (Unduplicated) With at Least One Service 995
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Center 05
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 6004 41209.250000 128550.8500 128550.8500
D 14 5.250000 195.3000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4421 8636.250000 80197.8800 22063.5800
Other 1 1.000000 37.2000 0.0000
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Total 10440 49851.750000 208981.2300 150614.4300