CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 657 654.000000 24328.8000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 405 1513.750000 56311.5000 37.2000
Subtotal (Total Children Is Unduplicated) 871 2167.750000 80640.3000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 12 10.750000 537.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 138.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 12.000000 900.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 31 45.500000 3412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 6.500000 487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 23 32.000000 2414.9500 75.4672
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 9.000000 499.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 52 78.000000 4340.0500 55.6417
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 46.500000 3493.4800 75.1286
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 102 278.250000 18683.5500 67.1466
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 32 57.000000 2850.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 6.000000 300.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 304 2912.000000 145600.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 6 24.500000 1225.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 937 9267.000000 139005.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 290 2648.000000 31776.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 32.000000 2302.7200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 7 41.000000 2950.3600 71.9600
PHY-97110HM-PT SESSION BY PT ASST 2 11.000000 633.1600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 26.000000 1870.9600 71.9600
Subtotal (Total Children Is Unduplicated) 1192 15026.50000 328613.2000 21.8689
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Total 17472.500000 427937.0500 24.4920
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Number of Children (Unduplicated) With at Least One Service 1612
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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 15125 15010.500000 327994.0200 327994.0200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 8.000000 260.0000 60.0000
T 0 0.000000 0.0000 0.0000
2109 2444.000000 99221.0300 0.0000
Other 10 10.000000 462.0000 -338.0000
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Total 17252 17472.500000 427937.0500 327716.0200