CMS/EIP Fiscal Report Center: 09
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 1161 2048.000000 76279.8000 37.2460
TCM-T1017TL-TARGETED CASE MANAGEMENT 739 2395.750000 89159.1000 37.2155
Subtotal (Total Children Is Unduplicated) 1422 4443.750000 165438.9000 37.2296
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 209 366.000000 18300.0000 50.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.500000 688.3300 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 30.000000 2429.4000 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 647.8400 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 20 39.500000 3198.7100 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.500000 931.2700 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 809.8000 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 12 23.000000 1378.1600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 31 59.500000 3596.8300 60.4509
NUTR-97802-NUTRITIONAL EVAL, INITIAL 9 56.000000 2800.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 24 139.000000 6950.0000 50.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 7 39.000000 2266.2900 58.1100
Subtotal (Total Children Is Unduplicated) 301 797.000000 44449.1400 55.7706
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 120 218.750000 10937.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 7 9.500000 475.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 53 55.250000 1381.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 10 11.000000 500.0000 45.4545
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 20.500000 1025.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 15 15.000000 750.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 15.000000 750.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 6 6.000000 300.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 60 148.250000 161.9600 1.0925
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 473 2690.000000 145155.0000 53.9610
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 16.000000 864.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 834 5535.000000 39297.0000 7.0997
INTR-T1013-INTERPRETER 97 455.250000 22762.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 167 907.000000 10776.0000 11.8809
OCCT-97530-OT SESSION BY LICENSED OT 39 190.000000 15450.8000 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 2 2.000000 162.6400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 6 21.000000 1367.5200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 55 299.000000 24314.6800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 2 9.000000 586.0800 65.1200
PHY-97110HMGT-PT SESSION BY PT ASST 1 2.000000 130.2400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 59 348.750000 27628.4700 79.2214
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
TRAV-TRAVS-Travel by mile 1147 93478.00000 41613.6500 0.4452
Subtotal (Total Children Is Unduplicated) 1320 104456.2500 346570.6100 3.3179
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Total 109697.000000 556458.6500 5.0727
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Number of Children (Unduplicated) With at Least One Service 1895
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Center 09
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 11916 56312.250000 273982.6900 273982.6900
D 169 818.500000 3043.2300 0.0000
S 876 6416.000000 17537.6900 0.0000
H 0 0.000000 0.0000 0.0000
T 5798 23802.250000 143179.6700 143179.6700
4836 22299.000000 115073.7800 0.0000
Other 25 49.000000 3641.5900 0.0000
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Total 23620 109697.000000 556458.6500 417162.3600