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: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 450 1752.500000 65193.0000 37.2000
Subtotal (Total Children Is Unduplicated) 947 2460.750000 91539.9000 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 1 1.000000 75.0000 75.0000
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 3 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 16.500000 1237.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 43 61.000000 4575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 9.000000 675.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 31 41.500000 3136.4200 75.5764
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 13.000000 721.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 73 104.500000 5817.4300 55.6692
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 12.500000 937.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 60.000000 4514.9500 75.2492
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 132 362.250000 24374.3700 67.2860
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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 17849.500000 444527.4700 24.9042
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Number of Children (Unduplicated) With at Least One Service 1689
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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
2387 2821.000000 115811.4500 0.0000
Other 10 10.000000 462.0000 -338.0000
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Total 17530 17849.500000 444527.4700 327716.0200