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
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 500 277.750000 10304.6500 37.1005
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 23 13.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 390 1165.500000 43170.6000 37.0404
Subtotal (Total Children Is Unduplicated) 700 1456.250000 53475.2500 36.7212
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 7 14.000000 838.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 809.8000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 323.9200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1133.7200 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 92.000000 5512.6400 59.9200
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SCREEN-T1023-SCREENING 3 3.000000 161.9400 53.9800
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 63 145.000000 9383.0000 64.7103
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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 3 2.750000 137.5000 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 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 41 173.250000 9369.0000 54.0779
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 14.000000 756.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 392 1929.000000 28929.0000 14.9969
INTR-T1013-INTERPRETER 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 303 1221.000000 14652.0000 12.0000
OCCT-97530HM-OT SESSION BY OT ASST 1 5.000000 325.6000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 3 15.750000 1280.7900 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 12.000000 975.8400 81.3200
TRAV-TRAVS-Travel by mile 359 23371.00000 10396.9800 0.4449
Subtotal (Total Children Is Unduplicated) 672 27333.00000 82335.2800 3.0123
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Total 28934.250000 145193.5300 5.0181
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Number of Children (Unduplicated) With at Least One Service 937
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Center 52
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 0 0.000000 0.0000 0.0000
S 9 8.750000 316.2000 0.0000
H 0 0.000000 0.0000 0.0000
T 5117 26911.250000 74539.2600 73393.9700
3047 2014.250000 70338.0700 30.0000
Other 0 0.000000 0.0000 0.0000
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Total 8173 28934.250000 145193.5300 73423.9700