CMS/EIP Fiscal Report Center: 52
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 785 771.500000 28653.3000 37.1397
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 53 31.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 417 1966.250000 72688.8000 36.9682
Subtotal (Total Children Is Unduplicated) 902 2769.000000 101342.1000 36.5988
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Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 2 4.000000 222.0000 55.5000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 485.8800 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 15 32.000000 1882.0800 58.8150
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 16.000000 1223.9200 76.4950
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 773.9200 77.3920
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 56.000000 3196.4000 57.0786
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 109.5200 54.7600
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
SCREEN-T1023-SCREENING 9 9.000000 477.8600 53.0956
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 60 143.000000 8863.5800 61.9831
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 158 199.000000 10012.6400 50.3148
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 171 213.250000 10662.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 82 66.750000 1706.2500 25.5618
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 121 435.250000 21750.0000 49.9713
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 17 16.250000 812.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 7 4.250000 106.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 68 104.750000 5275.1400 50.3593
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 4 2.250000 112.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.250000 6.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 53 293.500000 14750.0000 50.2555
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 5 4.500000 225.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 55 129.500000 6475.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 5 3.250000 162.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 287 1087.500000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 8 14.000000 700.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 70 666.750000 35129.0000 52.6869
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 63.000000 3378.0000 53.6190
EPIC-99601-Early Steps Professional Development Fee 500 7421.000000 111312.0000 14.9996
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 511 5667.000000 68004.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 21.000000 1604.7600 76.4171
OCCT-97530GO-OT SESSION BY LICENSED OT 2 6.000000 441.1200 73.5200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 4 5.750000 467.5900 81.3200
PHY-97110-PT SESSION BY LICENSED PT 6 83.750000 6735.6700 80.4259
PHY-97110HM-PT SESSION BY PT ASST 2 4.000000 245.3600 61.3400
PHY-97110TL-PT SESSION BY LICENSED PT 2 3.000000 215.8800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 44.000000 3411.4000 77.5318
TRAV-TRAVS-Travel by mile 538 105581.0000 46970.1000 0.4449
Subtotal (Total Children Is Unduplicated) 848 122141.5000 350696.4100 2.8712
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Total 125053.500000 460902.0900 3.6856
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Number of Children (Unduplicated) With at Least One Service 997
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Center 52
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 13 14.000000 682.0000 0.0000
S 7 10.000000 372.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 21882 120388.250000 314222.8600 308022.4100
8104 4641.250000 145625.2300 42.0000
Other 0 0.000000 0.0000 0.0000
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Total 30006 125053.500000 460902.0900 308064.4100