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
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 679 713.500000 26542.2000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 506 2050.500000 76278.6000 37.2000
Subtotal (Total Children Is Unduplicated) 913 2764.000000 102820.8000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 15 12.000000 600.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 121.4700 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.500000 149.8000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 10.000000 599.2000 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 6.000000 485.8800 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 24.000000 1438.0800 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 57 74.000000 4434.0800 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 3.500000 283.4300 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 80.9800 80.9800
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 102 136.500000 8332.0100 61.0404
-----------------------------------------------------------------------------------------------------------------------
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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 237 1608.000000 86832.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 6.750000 364.5000 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 3 6.500000 528.5800 81.3200
PHY-97110-PT SESSION BY LICENSED PT 5 14.500000 1179.1400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 8.000000 520.9600 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 11.500000 935.1800 81.3200
Subtotal (Total Children Is Unduplicated) 959 7729.250000 179115.3600 23.1737
-----------------------------------------------------------------------------------------------------------------------
Total 10629.750000 290268.1700 27.3071
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1533
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 7754 7708.500000 178703.9700 178703.9700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 19.000000 363.0000 363.0000
T 0 0.000000 0.0000 0.0000
2420 2900.250000 111132.2000 0.0000
Other 2 2.000000 69.0000 69.0000
---------------------------------------------------------
Total 10195 10629.750000 290268.1700 179135.9700