CMS/EIP Fiscal Report Center: 54
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 218 127.750000 4752.3000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 30 21.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 233 553.750000 20580.9000 37.1664
Subtotal (Total Children Is Unduplicated) 391 703.000000 25333.2000 36.0358
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 4 4.000000 194.0000 48.5000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
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 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.500000 769.3100 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 323.9200 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 80.9800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 299.6000 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 12.000000 719.0400 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 323.9200 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 607.3500 80.9800
Subtotal (Total Children Is Unduplicated) 23 59.000000 4247.7600 71.9959
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 15.000000 5877.3300 391.8220
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 37 42.750000 2137.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 132 146.500000 7312.5000 49.9147
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 24 26.000000 1300.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 66 32.500000 1625.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 6 6.500000 162.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 5.250000 262.5000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 106 58.250000 2912.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 2.000000 75.0000 37.5000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 8.250000 412.5000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 53 24.500000 1225.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 10 16.000000 800.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 74 35.500000 1775.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
DSTT-DSTT-DIRECT SERVICE PERSONNEL TRAVEL 260 1009.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 76 368.000000 19872.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 29 57.500000 3105.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 401 2235.000000 33525.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 242 1201.000000 14412.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 54.000000 4391.2800 81.3200
OCCT-97530GO-OT SESSION BY LICENSED OT 8 23.000000 1870.3600 81.3200
OCCT-97530GOGT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.000000 212.6400 70.8800
OCCT-97530HM-OT SESSION BY OT ASST 4 18.000000 1172.1600 65.1200
OCCT-97530HMGT-OT SESSION BY OT ASST 1 3.000000 195.3600 65.1200
PHY-97110-PT SESSION BY LICENSED PT 20 67.500000 5489.1000 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 1 3.000000 243.9600 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 77.750000 6322.6300 81.3200
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 4.000000 325.2800 81.3200
TRAV-TRAVS-Travel by mile 386 31913.00000 14196.7600 0.4449
Subtotal (Total Children Is Unduplicated) 608 37457.25000 131304.6800 3.5055
-----------------------------------------------------------------------------------------------------------------------
Total 38219.250000 160885.6400 4.2095
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 710
-----------------------------------------------------------------------------------------------------------------------
Center 54
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 0 0.000000 0.0000 0.0000
D 74 55.250000 2865.7900 0.0000
S 4 3.250000 133.9300 0.0000
H 0 0.000000 0.0000 0.0000
T 2686 19643.500000 42452.1600 42452.1600
6364 18514.750000 115340.7600 0.0000
Other 5 2.500000 93.0000 0.0000
---------------------------------------------------------
Total 9133 38219.250000 160885.6400 42452.1600