CMS/EIP Fiscal Report Center: 52
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 214 134.750000 4994.1000 37.0620
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 7 3.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 134 270.500000 10034.7000 37.0969
Subtotal (Total Children Is Unduplicated) 279 408.750000 15028.8000 36.7677
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Screening, Eval, and Assessment,Class #02
IPDEF-IPDEF_NM-F/U PSYCH & DEV EVAL BY NON-MED PROF 1 2.000000 111.0000 55.5000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 479.3600 59.9200
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 3 6.000000 359.5200 59.9200
SCREEN-T1023-SCREENING 2 2.000000 107.9600 53.9800
Subtotal (Total Children Is Unduplicated) 10 22.000000 1381.7600 62.8073
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 27 27.750000 1387.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 30 35.250000 1762.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 19 13.000000 350.0000 26.9231
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 33 63.250000 3162.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 5 4.250000 212.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 12 15.500000 806.3200 52.0206
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 2 1.000000 50.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.250000 6.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 23 57.500000 2875.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 18 33.750000 1687.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 88 188.000000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 24 109.750000 5922.5000 53.9636
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 13.000000 702.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 217 1359.000000 20385.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 160 934.000000 11208.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 243.9600 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530TLGO-OT SESSION BY LICENSED OT 1 2.750000 223.6300 81.3200
PHY-97110-PT SESSION BY LICENSED PT 5 37.000000 3008.8400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 130.2400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 325.2800 81.3200
TRAV-TRAVS-Travel by mile 215 20659.00000 9190.8600 0.4449
Subtotal (Total Children Is Unduplicated) 342 23568.00000 63921.7000 2.7122
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Total 23998.750000 80332.2600 3.3474
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Number of Children (Unduplicated) With at Least One Service 389
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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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3926 23236.750000 55487.1900 54489.1900
1386 762.000000 24845.0700 30.0000
Other 0 0.000000 0.0000 0.0000
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Total 5312 23998.750000 80332.2600 54519.1900