CMS/EIP Fiscal Report Center: 05
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 682 434.500000 16182.0000 37.2428
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 328 357.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 482 2492.250000 92711.7000 37.2000
Subtotal (Total Children Is Unduplicated) 873 3284.250000 108893.7000 33.1563
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 2 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 24.500000 1930.1900 78.7833
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 12 21.500000 1711.1700 79.5893
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 9.500000 760.3400 80.0358
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 15.000000 1178.8200 78.5880
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.000000 392.9400 78.5880
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 22 28.000000 1706.7400 60.9550
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 19 35.000000 2039.7400 58.2783
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 39.500000 2986.4200 75.6056
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 18 30.500000 2350.2900 77.0587
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.000000 647.8400 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 26.000000 1970.9300 75.8050
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 8.500000 646.4700 76.0553
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 26 41.000000 2341.8000 57.1171
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 28 51.500000 2909.0800 56.4870
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 312.8000 44.6857
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 58.1100 58.1100
SPCH-92610GT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 23.8900 23.8900
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 5 21.000000 665.9400 31.7114
Subtotal (Total Children Is Unduplicated) 137 387.500000 25423.5100 65.6091
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 24 37.000000 4088.7400 110.5065
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 210 271.250000 13550.0000 49.9539
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 73 71.000000 3550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 10 9.250000 231.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 85 176.250000 8791.5000 49.8809
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 31 108.250000 5412.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 13 12.750000 318.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 36 40.000000 2000.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 31 197.750000 9887.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 39 44.500000 2225.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 11 17.250000 862.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 50 54.000000 2700.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 33 37.000000 1850.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 5 2.750000 68.7500 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 12.000000 308.0000 25.6667
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 8 23.500000 1199.0000 51.0213
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 176 2002.750000 105460.5000 52.6578
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 17 82.500000 4325.0000 52.4242
EPIC-99601-Early Steps Professional Development Fee 499 8382.000000 125670.0000 14.9928
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 289 2680.000000 32160.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 255.250000 18245.8100 71.4821
PHY-97110-PT SESSION BY LICENSED PT 42 199.250000 13816.2400 69.3412
PHY-97110GT-PT SESSION BY LICENSED PT 2 16.000000 1291.7600 80.7350
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 132.000000 9850.9100 74.6281
TRAV-TRAVS-Travel by mile 609 147123.0000 65435.4900 0.4448
Subtotal (Total Children Is Unduplicated) 722 161987.2500 433299.2000 2.6749
-----------------------------------------------------------------------------------------------------------------------
Total 165659.000000 567616.4100 3.4264
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 959
-----------------------------------------------------------------------------------------------------------------------
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 24093 160932.750000 451329.6000 451329.6000
D 127 66.750000 2483.1000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6921 4657.000000 113710.7100 7393.1100
Other 5 2.500000 93.0000 0.0000
---------------------------------------------------------
Total 31146 165659.000000 567616.4100 458722.7100