CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2025 ending 03/31/2025 Date of Report:04/06/2025 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 193 314.750000 11708.7000 37.2000
Subtotal (Total Children Is Unduplicated) 193 314.750000 11708.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.000000 647.8400 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 566.8600 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.000000 599.2000 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.500000 269.6400 59.9200
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 36 56.500000 4575.3700 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 34 47.000000 3846.5500 81.8415
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 48.500000 3927.5300 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 65 101.500000 8219.4700 80.9800
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 161.9600 80.9800
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 5.500000 445.3900 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 105.500000 6321.5600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 91 133.000000 7999.3200 60.1453
Subtotal (Total Children Is Unduplicated) 178 534.500000 38026.0800 71.1433
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 5 6.500000 325.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 56 219.000000 11826.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 89 400.000000 1884.0000 4.7100
OCCT-97530-OT SESSION BY LICENSED OT 20 70.000000 5692.4000 81.3200
PHY-97110-PT SESSION BY LICENSED PT 18 72.750000 5916.0300 81.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 110.000000 8945.2000 81.3200
TRAV-TRAVS-Travel by mile 111 4608.000000 2049.2900 0.4447
Subtotal (Total Children Is Unduplicated) 144 5489.250000 36762.9200 6.6973
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Total 6338.500000 86497.7000 13.6464
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Number of Children (Unduplicated) With at Least One Service 349
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Center 09
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 601 2360.500000 18019.2800 18019.2800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 489 758.500000 45089.2600 0.0000
T 795 3157.750000 21092.0600 21092.0600
66 61.750000 2297.1000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1951 6338.500000 86497.7000 39111.3400