CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2025 ending 03/31/2025 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 679 713.500000 26542.2000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1256 4903.750000 182419.5000 37.2000
Subtotal (Total Children Is Unduplicated) 1280 5617.250000 208961.7000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 15 12.000000 600.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.500000 283.4300 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 16 19.500000 1579.1100 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 3.000000 242.9400 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 7.500000 607.3500 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 5 6.000000 359.5200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 16 26.000000 1557.9200 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 1 3.000000 242.9400 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 4 5.000000 404.9000 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 47 60.500000 4899.2900 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 109 133.000000 10770.3400 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 25.000000 2024.5000 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 66 80.500000 6518.8900 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 70 101.000000 6051.9200 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 176 278.000000 16657.7600 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 62.000000 5020.7600 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 99 157.000000 12713.8600 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 55 55.000000 7202.9000 130.9618
OCTH-97165-OT EVAL LOW COMPLEXITY 8 8.000000 464.8800 58.1100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 348.6600 58.1100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 10 10.000000 581.1000 58.1100
Subtotal (Total Children Is Unduplicated) 322 1068.500000 79539.7400 74.4406
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 21 31.000000 1550.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 100 2197.000000 59319.0000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 920 5883.000000 317682.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 11 46.750000 2524.5000 54.0000
EPIC-99601-Early Steps Professional Development Fee 763 4871.000000 73065.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 180 1170.000000 14040.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 39 118.500000 9636.4200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 40 143.000000 9312.1600 65.1200
PHY-97110-PT SESSION BY LICENSED PT 43 119.000000 9677.0800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 32 109.000000 7098.0800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 66 218.500000 17768.4200 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 12 52.500000 3418.8000 65.1200
Subtotal (Total Children Is Unduplicated) 1059 14961.25000 525191.4600 35.1034
-----------------------------------------------------------------------------------------------------------------------
Total 21647.000000 813692.9000 37.5892
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1744
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 69 94.250000 3506.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 1202 1929.750000 76993.1000 0.0000
P 8010 8168.250000 196307.6600 196313.7200
D 18 32.250000 1199.7000 0.0000
S 4 10.250000 381.3000 0.0000
H 4484 4469.000000 243337.1000 363.0000
T 0 0.000000 0.0000 0.0000
5313 6880.250000 287297.9400 0.0000
Other 102 63.000000 4670.0000 69.0000
---------------------------------------------------------
Total 19202 21647.000000 813692.9000 196745.7200