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
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 1071 1242.750000 46230.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 563 2923.250000 108744.9000 37.2000
Subtotal (Total Children Is Unduplicated) 1261 4166.000000 154975.2000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 43 33.500000 1675.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 196.4700 78.5880
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 20.500000 1573.3800 76.7502
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 4 4.500000 343.4800 76.3289
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 10 14.000000 827.8300 59.1307
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 21 27.000000 1571.4300 58.2011
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 8.500000 637.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 32.500000 2446.4700 75.2760
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 17 24.000000 1805.9800 75.2492
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.500000 311.8800 56.7055
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 44 65.500000 3648.5100 55.7024
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.500000 412.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 43.500000 3268.4800 75.1375
OCTH-97165-OT EVAL LOW COMPLEXITY 5 6.000000 348.6600 58.1100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 7 9.000000 509.5900 56.6211
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 174.3300 58.1100
Subtotal (Total Children Is Unduplicated) 139 312.000000 20242.7100 64.8805
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 54 202.250000 10112.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 5.000000 250.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 5 5.000000 250.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 2 3.000000 150.0000 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 326 7608.000000 399400.0000 52.4974
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 42.000000 2170.0000 51.6667
EPIC-99601-Early Steps Professional Development Fee 986 26845.00000 402675.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 318 6084.000000 73008.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 103.500000 8117.1000 78.4261
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 9 133.500000 10472.4600 78.4454
PHY-97110HM-PT SESSION BY PT ASST 2 34.000000 2130.9200 62.6741
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 77.000000 6018.2800 78.1595
Subtotal (Total Children Is Unduplicated) 1224 41152.25000 915261.8600 22.2409
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Total 45630.250000 1090479.7700 23.8982
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Number of Children (Unduplicated) With at Least One Service 1592
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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 41471 41111.750000 914239.7900 914215.7900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 28 28.000000 577.1100 507.0000
T 0 0.000000 0.0000 0.0000
3833 4462.000000 174129.1100 60.0000
Other 38 28.500000 1533.7600 -275.0000
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Total 45370 45630.250000 1090479.7700 914507.7900