CMS/EIP Fiscal Report Center: 05
Services beginning 04/01/2025 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 173 71.500000 2659.8000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 70 64.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 165 358.250000 13326.9000 37.2000
Subtotal (Total Children Is Unduplicated) 282 494.000000 15986.7000 32.3617
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 4.500000 364.4100 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.000000 299.6000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 239.6800 59.9200
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 6.000000 163.8000 27.3000
Subtotal (Total Children Is Unduplicated) 15 34.000000 2145.7300 63.1097
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 11.000000 1324.3100 120.3918
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 57 57.250000 2850.0000 49.7817
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 12 12.250000 612.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.500000 37.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 27 55.500000 2775.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 4 3.500000 175.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 4.000000 100.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 7 4.500000 225.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 15 43.000000 2150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 10.250000 512.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 4 3.750000 187.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 5.750000 287.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 5 4.750000 237.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 27.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 66 306.750000 16564.5000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 6 19.000000 1026.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 216 1479.000000 22185.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 70 327.000000 3924.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 49.500000 3699.7400 74.7422
PHY-97110-PT SESSION BY LICENSED PT 13 22.000000 1352.0100 61.4550
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 34.000000 2662.7800 78.3171
TRAV-TRAVS-Travel by mile 220 23885.00000 10621.5200 0.4447
Subtotal (Total Children Is Unduplicated) 289 26340.25000 73536.8600 2.7918
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Total 26868.250000 91669.2900 3.4118
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Number of Children (Unduplicated) With at Least One Service 361
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Center 05
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 3775 25541.250000 72050.7100 72050.7100
D 19 7.000000 260.4000 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
1253 1317.750000 19274.4800 3631.8800
Other 4 2.250000 83.7000 0.0000
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Total 5051 26868.250000 91669.2900 75682.5900