CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2024 ending 03/31/2024 Date of Report:04/04/2025 Page: 1
List order: No List
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 744 782.500000 29109.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1568 6717.500000 249752.5000 37.1794
Subtotal (Total Children Is Unduplicated) 1598 7500.000000 278861.5000 37.1815
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 6 5.250000 262.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 14 21.000000 1575.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 22 39.500000 2192.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 52.500000 3937.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 158 220.500000 16537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 13.500000 1012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 108 149.500000 11212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 68.500000 3801.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 267 517.000000 28693.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 65.500000 4912.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 183 323.000000 24225.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 81 81.000000 10953.0000 135.2222
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 62.9400 31.4700
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 18 18.000000 882.5100 49.0283
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 16 16.000000 843.1100 52.6944
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 17 17.000000 873.9700 51.4100
Subtotal (Total Children Is Unduplicated) 450 1630.750000 113239.1300 69.4399
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 25 39.000000 1950.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.000000 150.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 38 285.000000 7125.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 10.000000 500.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1175 11297.50000 564875.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 31 154.500000 7725.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 845 8413.000000 126195.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 390 3289.000000 39468.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 46 253.000000 18229.2800 72.0525
OCCT-97530HM-OT SESSION BY OT ASST 16 107.500000 6192.0000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 2 14.000000 1007.4400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 62 287.000000 20692.1200 72.0980
PHY-97110HM-PT SESSION BY PT ASST 23 204.000000 11731.3600 57.5067
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 243.000000 17519.0400 72.0948
Subtotal (Total Children Is Unduplicated) 1308 24604.00000 823559.2400 33.4726
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Total 33734.750000 1215659.8700 36.0358
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Number of Children (Unduplicated) With at Least One Service 1929
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Center 04
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 425 726.500000 29611.2000 0.0000
P 17982 19249.750000 519999.2000 508676.7300
D 45 62.500000 2773.8000 0.0000
S 0 0.000000 0.0000 0.0000
H 8771 8726.500000 441020.1200 0.0000
T 0 0.000000 0.0000 0.0000
3958 4780.000000 213294.9700 0.0000
Other 292 189.500000 8960.5800 -854.0000
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Total 31473 33734.750000 1215659.8700 507822.7300