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
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 744 782.500000 29109.0000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 558 2472.750000 91847.8000 37.1440
Subtotal (Total Children Is Unduplicated) 1055 3255.250000 120956.8000 37.1575
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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 1 1.000000 75.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 16.000000 1200.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 47 66.500000 4987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 41 55.500000 4162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 20.500000 1137.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 96 137.500000 7631.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 14.500000 1087.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 43 58.000000 4350.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 3 3.000000 228.4500 76.1500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 147 412.750000 27338.5700 66.2352
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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
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 10.000000 500.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 326 3032.500000 151625.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 50.500000 2525.0000 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 6 22.500000 1619.1000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 2 10.000000 576.0000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 10 56.500000 4065.7400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 5 39.000000 2244.8400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 28.500000 2050.8600 71.9600
Subtotal (Total Children Is Unduplicated) 1223 14998.00000 333169.5400 22.2143
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Total 18666.000000 481464.9100 25.7937
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Number of Children (Unduplicated) With at Least One Service 1703
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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 0 0.000000 0.0000 0.0000
P 15032 14918.500000 331973.5500 331973.5500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 5.000000 250.0000 0.0000
T 0 0.000000 0.0000 0.0000
2883 3661.000000 147935.5000 0.0000
Other 85 81.500000 1305.8600 -854.0000
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Total 18005 18666.000000 481464.9100 331119.5500