CMS/EIP Fiscal Report Center: 55
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 1117 1007.500000 38399.7000 38.1138
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 94 98.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1424 6636.500000 246775.5000 37.1846
Subtotal (Total Children Is Unduplicated) 1481 7742.500000 285175.2000 36.8324
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 24 48.000000 3887.0400 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 647.8400 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 10.000000 809.8000 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 19 38.000000 2276.9600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 161.9600 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 275 555.000000 44943.9000 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 50 99.000000 8017.0200 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 52 104.000000 8421.9200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 22.000000 1781.5600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 53 106.000000 8583.8800 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1295.6800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 116 233.000000 13961.3600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 27 54.000000 3235.6800 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 13 13.000000 755.4300 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 11 12.000000 697.3200 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 6.000000 348.6600 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 6.000000 348.6600 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 290.5500 58.1100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 421 1349.000000 101215.5200 75.0300
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 8 7.500000 375.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 0.500000 25.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 3 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 16 16.000000 800.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 52 29.000000 725.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 19 38.000000 1900.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 22 58.000000 1450.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 12 12.000000 600.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 52 29.000000 725.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 338 1304.000000 70416.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 27 75.500000 4077.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 328 1472.000000 22080.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 310 1222.000000 14664.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 70 304.499998 24761.9400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 82 378.499999 24647.9200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 49 217.750000 17707.4300 81.3200
PHY-97110HM-PT SESSION BY PT ASST 53 249.875297 16288.1600 65.1852
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 184 736.250000 59871.8500 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 14.000000 1138.4800 81.3200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 18 61.000000 4960.5200 81.3200
Subtotal (Total Children Is Unduplicated) 713 6226.875294 267250.8000 42.9189
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Total 15318.375294 653641.5200 42.6704
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Number of Children (Unduplicated) With at Least One Service 1511
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Center 55
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 3363 3533.750000 154350.3600 0.0000
P 3054 3029.751630 94096.4300 94096.4300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 26 47.000000 3742.4300 0.0000
T 759 746.766780 25785.4600 25785.4600
9180 7961.106884 375666.8400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 16382 15318.375294 653641.5200 119881.8900