CMS/EIP Fiscal Report Center: 57
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 599 441.250000 16414.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 655 2592.250000 96431.7000 37.2000
Subtotal (Total Children Is Unduplicated) 1003 3033.500000 112846.2000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 2 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 242.9400 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 404.9000 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 121.4700 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 10.500000 629.1600 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 89.8800 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 26.500000 2145.9700 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 44.500000 3603.6100 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 404.9000 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 26.500000 2145.9700 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 121.4700 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 58 102.000000 6111.8400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.000000 419.4400 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 232.4400 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 80 253.500000 17542.7200 69.2021
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 1.500000 75.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 81 82.000000 4100.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 30 30.000000 1500.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 146 146.000000 7300.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 84 84.000000 4200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 482 3353.750000 181102.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 11 21.000000 1134.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 914 5802.000000 87030.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 376 2182.000000 26184.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 25.000000 2033.0000 81.3200
PHY-97110-PT SESSION BY LICENSED PT 2 7.500000 609.9000 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 3 3.000000 243.9600 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 5.000000 325.6000 65.1200
TRAV-TRAVS-Travel by mile 9 2757.000000 1226.8200 0.4450
Subtotal (Total Children Is Unduplicated) 1251 14504.75000 317314.7800 21.8766
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Total 17791.750000 447703.7000 25.1636
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Number of Children (Unduplicated) With at Least One Service 1667
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Center 57
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 109 109.000000 3212.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.500000 18.6000 18.6000
T 7023 8468.250000 184283.9500 184283.9500
7482 9214.000000 260189.1500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14615 17791.750000 447703.7000 184302.5500