CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
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 500 277.750000 10304.6500 37.1005
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 23 13.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 788 2430.750000 89819.4000 36.9513
Subtotal (Total Children Is Unduplicated) 887 2721.500000 100124.0500 36.7900
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 46.000000 3563.1200 77.4591
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 647.8400 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 20 40.000000 2396.8000 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 115 235.000000 18509.4200 78.7635
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 20.000000 1619.6000 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 90.000000 7207.2200 80.0802
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 43 87.000000 6868.3000 78.9460
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 155 309.000000 18515.2800 59.9200
OCTH-97166-OT EVAL MODERATE COMPLEXITY 8 8.000000 464.8800 58.1100
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SCREEN-T1023-SCREENING 13 13.000000 701.7400 53.9800
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 232.4400 58.1100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 3.000000 109.4300 36.4767
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 13 56.000000 2891.5500 51.6348
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 245 935.000000 64794.6000 69.2990
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 42 44.250000 2243.8200 50.7078
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 41 46.250000 2312.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 25 23.250000 581.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 52 71.750000 3575.0000 49.8258
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 4 3.250000 162.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 1.500000 37.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 24 27.750000 1387.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 0.250000 12.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 28 59.500000 3037.5000 51.0504
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 25 41.000000 2050.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 2 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 202 268.250000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 4 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 464 2005.750000 108277.8500 53.9837
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 20 87.000000 4698.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 392 1930.000000 28944.0000 14.9969
INTR-T1013-INTERPRETER 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 303 1222.000000 14664.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 28.000000 2276.9600 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 11 30.000000 2439.6000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 3 8.000000 520.9600 65.1200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 24 92.500000 7522.1000 81.3200
OCCT-97530TLHM-OT SESSION BY OT ASST 3 5.000000 325.6000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 40 141.500000 10374.3500 73.3170
PHY-97110HM-PT SESSION BY PT ASST 8 13.000000 846.5600 65.1200
PHY-97110TL-PT SESSION BY LICENSED PT 29 82.750000 6677.9100 80.6998
PHY-97110TLHM-PT SESSION BY PT ASST 7 36.000000 2344.3200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 60 244.000000 18747.5600 76.8343
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 35 131.000000 10693.5800 81.6304
TRAV-TRAVS-Travel by mile 359 23371.00000 10396.9800 0.4449
Subtotal (Total Children Is Unduplicated) 674 30021.00000 245475.4000 8.1768
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Total 33677.500000 410394.0500 12.1860
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Number of Children (Unduplicated) With at Least One Service 1006
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Center 52
Flag Claims Units Chgs Paid
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R 55 59.000000 3869.5500 0.0000
U 0 0.000000 0.0000 0.0000
B 575 624.500000 26538.6400 0.0000
P 1474 1571.000000 81102.3100 80148.8300
D 48 54.750000 4487.4900 0.0000
S 43 48.750000 1908.5600 32.3900
H 78 91.000000 7054.3100 0.0000
T 6127 27967.750000 136726.6800 128067.9000
4134 3251.500000 148396.8100 30.0000
Other 8 9.250000 309.7000 281.8000
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Total 12542 33677.500000 410394.0500 208560.9200