CMS/EIP Fiscal Report Center: 55
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 1236 2024.500000 75303.8500 37.1963
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 225 242.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 873 5676.750000 211148.9500 37.1954
Subtotal (Total Children Is Unduplicated) 1323 7944.000000 286452.8000 36.0590
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 27 53.000000 4208.2200 79.4004
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 635.8800 79.4850
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 785.8800 78.5880
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 323.9200 80.9800
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 24.000000 1907.6400 79.4850
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 35 69.000000 4081.4400 59.1513
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 8.000000 479.3600 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 97.885733 7520.8300 76.8327
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 22.000000 1685.8800 76.6309
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 30.000000 2333.7200 77.7907
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1223.9200 76.4950
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 41.885733 3237.1100 77.2843
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 86.000000 4843.7200 56.3223
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 16.000000 914.5200 57.1575
OCTF-97168-OT RE-EVAL EST PLAN CARE 23 24.474270 1388.0300 56.7138
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 1.092005 56.1400 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 19 18.428516 1001.0100 54.3185
PSTF-97164-PT RE-EVAL EST PLAN CARE 10 11.634113 642.6300 55.2367
PSTH-97162-PT EVAL MODERATE COMPLEXITY 9 8.168158 459.6200 56.2697
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 212.3400 53.0850
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 19 20.509895 1118.1300 54.5166
Subtotal (Total Children Is Unduplicated) 227 574.078423 39059.9400 68.0394
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 242.8000 121.4000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 35 36.750000 1837.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 5 4.000000 200.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 11 5.750000 143.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 156 246.000000 12300.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 15 17.000000 850.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 101 210.000000 5250.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 56 170.500000 8300.0000 48.6804
CONOP-CONOP-CONSULT, OT, PHONE 34 238.000000 5950.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 142 232.000000 11575.0000 49.8922
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 11 13.000000 650.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 100 211.500000 5287.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 199 3378.750000 176929.5000 52.3654
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 76.750000 4048.5000 52.7492
EPIC-99601-Early Steps Professional Development Fee 455 8009.000000 120135.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 528 8649.000000 103853.9600 12.0076
OCCT-97530-OT SESSION BY LICENSED OT 58 603.505613 46598.0500 77.2123
OCCT-97530HM-OT SESSION BY OT ASST 58 570.487769 35527.3300 62.2754
PHY-97110-PT SESSION BY LICENSED PT 34 420.325703 28697.7500 68.2750
PHY-97110HM-PT SESSION BY PT ASST 32 388.659332 24213.4300 62.2999
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 143 1361.086147 104345.0900 76.6631
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 22.000000 1789.0400 81.3200
TRAV-TRAVS-Travel by mile 2 140.000000 62.3000 0.4450
Subtotal (Total Children Is Unduplicated) 880 25006.06456 698786.5000 27.9447
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Total 33524.142987 1024299.2400 30.5541
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Number of Children (Unduplicated) With at Least One Service 1359
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Center 55
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 1 0.750000 27.9000 27.9000
P 23971 23562.245716 658345.1400 658361.0400
D 1 0.750000 27.9000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 119.8400 0.0000
T 1075 1021.799661 28005.3700 28005.3700
12176 8936.597610 337773.0900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 37225 33524.142987 1024299.2400 686394.3100