CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 2326 3124.250000 116222.1000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 3287 22482.25000 836339.7000 37.2000
Subtotal (Total Children Is Unduplicated) 3321 25606.50000 952561.8000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 49 39.500000 1975.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 27.500000 2191.0700 79.6753
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 64 81.000000 6430.8100 79.3927
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 7.000000 560.8800 80.1257
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 23 27.500000 2185.0900 79.4578
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 19 24.500000 1445.9400 59.0180
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 60 98.500000 5811.5100 59.0001
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 8 14.000000 1133.7200 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 16 19.500000 1579.1100 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 182 227.500000 18058.1700 79.3766
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 679 876.000000 69581.0200 79.4304
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 83 90.500000 7215.0700 79.7245
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 396 486.000000 38565.3000 79.3525
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 217 289.500000 17130.2600 59.1719
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1014 1684.500000 99032.1800 58.7903
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 192 317.000000 25252.0600 79.6595
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 657 1075.500000 85253.5200 79.2687
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 304.0000 304.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 295 295.000000 39309.5500 133.2527
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 109.5200 54.7600
OCTH-97165-OT EVAL LOW COMPLEXITY 70 86.000000 4852.7100 56.4269
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 174.3300 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 489.4900 54.3878
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 5 8.000000 458.1800 57.2725
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 52 66.000000 3674.0100 55.6668
PSTH-97161GT-PT EVAL LOW COMPLEXITY 4 6.000000 341.9600 56.9933
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 6.000000 348.6600 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 9.000000 502.8900 55.8767
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 5 5.000000 283.8500 56.7700
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 65 79.000000 4429.8900 56.0746
SPCH-92521TL-EVAL OF SPEECH FLUENCY 7 7.000000 379.9700 54.2814
SPCH-92522-EVAL OF SPCH SOUND PROD 7 7.000000 400.0700 57.1529
SPCH-92522TL-EVAL OF SPCH SOUND PROD 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 1668 5984.500000 440014.0900 73.5256
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 72 247.500000 12375.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 5.000000 250.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 8 8.000000 400.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 2 3.000000 150.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 155 10492.50000 280973.5000 26.7785
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 6.000000 300.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1848 43101.50000 2282340.2000 52.9527
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 40 277.000000 14724.0000 53.1552
EPIC-99601-Early Steps Professional Development Fee 1551 36505.00000 547575.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 485 8079.000000 96948.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 115 1173.000000 92116.9500 78.5311
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 153.2800 76.6400
OCCT-97530HM-OT SESSION BY OT ASST 87 912.500000 58358.6400 63.9547
OCCT-97530TL-OT SESSION BY LICENSED OT 2 2.000000 162.6400 81.3200
PHY-97110-PT SESSION BY LICENSED PT 113 1117.000000 89247.6800 79.8994
PHY-97110HM-PT SESSION BY PT ASST 62 737.500000 46782.6000 63.4340
PHY-97110TL-PT SESSION BY LICENSED PT 2 16.000000 1254.3200 78.3950
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 153 1511.500000 121150.8200 80.1527
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 12 123.000000 8009.7600 65.1200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 2083 104326.0000 3653666.3100 35.0216
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Total 135917.000000 5046242.2000 37.1274
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Number of Children (Unduplicated) With at Least One Service 3536
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Center 04
Flag Claims Units Chgs Paid
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R 201 312.250000 11615.7000 0.0000
U 0 0.000000 0.0000 0.0000
B 3798 5934.250000 255121.9500 0.0000
P 64269 67107.000000 1754019.2800 1710880.4400
D 173 262.500000 11799.6300 0.0000
S 6 14.750000 548.7000 0.0000
H 34207 33915.000000 1819660.7400 837.0000
T 2 4.000000 148.8000 0.0000
20690 27346.750000 1116938.7600 90.0000
Other 1718 1020.500000 76388.6400 -335.0000
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Total 125064 135917.000000 5046242.2000 1711472.4400