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
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 715 708.250000 26346.9000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1411 5706.750000 212291.1000 37.2000
Subtotal (Total Children Is Unduplicated) 1441 6415.000000 238638.0000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 12 10.750000 537.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 13 18.500000 1387.5000 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 6 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 19.000000 1054.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 59.000000 4430.9800 75.1014
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 170 230.500000 17338.3300 75.2205
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 19.000000 1425.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 107 140.500000 10577.7400 75.2864
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 47.500000 2636.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 239 425.500000 23641.5200 55.5617
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 68.500000 5137.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 180 316.000000 23814.9900 75.3639
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 78 78.000000 10408.1500 133.4378
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 24 24.000000 1267.3400 52.8058
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 17 17.000000 844.0700 49.6512
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 26 26.000000 1350.0600 51.9254
SPCH-92521TL-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 464 1541.750000 108374.7600 70.2933
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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
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 60 1979.000000 51109.0000 25.8257
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 6.000000 300.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1145 11435.00000 572470.0000 50.0630
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 70.500000 3589.0000 50.9078
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 62 329.500000 23638.5100 71.7405
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 24 155.500000 9046.0200 58.1738
PHY-97110-PT SESSION BY LICENSED PT 54 223.500000 16607.2200 74.3052
PHY-97110HM-PT SESSION BY PT ASST 32 176.000000 10228.8400 58.1184
PHY-97110TL-PT SESSION BY LICENSED PT 1 14.000000 1091.6800 77.9771
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 248.000000 18403.0000 74.2056
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 1291 26614.00000 880430.1500 33.0815
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Total 34570.750000 1227442.9100 35.5052
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Number of Children (Unduplicated) With at Least One Service 1896
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Center 04
Flag Claims Units Chgs Paid
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R 1 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 613 1005.000000 41294.3500 0.0000
P 17909 18833.000000 498725.5600 478196.5100
D 26 43.750000 2141.9700 0.0000
S 0 0.000000 0.0000 0.0000
H 8990 8928.500000 452419.0900 60.0000
T 1 1.500000 55.8000 0.0000
3743 5550.000000 218740.4200 0.0000
Other 290 206.000000 13954.1200 -338.0000
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Total 31573 34570.750000 1227442.9100 477918.5100