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
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 1117 1007.500000 38399.7000 38.1138
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 94 98.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 905 3597.250000 133780.5000 37.1897
Subtotal (Total Children Is Unduplicated) 1326 4703.250000 172180.2000 36.6088
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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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 719.0400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 44 88.000000 7126.2400 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 18.000000 1457.6400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 24.000000 1943.5200 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 12.000000 971.7600 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 50.000000 4049.0000 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 647.8400 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 104.000000 6231.6800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 22.000000 1318.2400 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 5.569781 323.6600 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 290.5500 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 137 353.569781 25461.2000 72.0118
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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 144 570.000000 30780.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 44.000000 2376.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 328 1470.000000 22050.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 310 1222.000000 14664.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 85.624694 6963.0000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 19 67.119317 4370.8100 65.1200
PHY-97110-PT SESSION BY LICENSED PT 17 56.025332 4555.9800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 11 56.073702 3651.5200 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 56 201.416382 16379.1800 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 8.000000 650.5600 81.3200
Subtotal (Total Children Is Unduplicated) 651 3971.759427 113078.5500 28.4706
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Total 9028.579208 310719.9500 34.4152
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Number of Children (Unduplicated) With at Least One Service 1449
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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 0 0.000000 0.0000 0.0000
P 2883 2867.014417 82386.7800 82386.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 119.8400 0.0000
T 688 672.266780 20309.7700 20309.7700
6808 5487.298011 207903.5600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10380 9028.579208 310719.9500 102696.5500