CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2025 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 702 766.000000 28495.2000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1282 5345.250000 198843.3000 37.2000
Subtotal (Total Children Is Unduplicated) 1320 6111.250000 227338.5000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 10 8.000000 400.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 10.000000 809.8000 80.9800
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 12 15.500000 1255.1900 80.9800
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 242.9400 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 6.000000 485.8800 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 8 11.000000 659.1200 59.9200
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 15 32.000000 1917.4400 59.9200
IPDEF-T1024TSTL-F/U PSYCH AND DEV EVAL BY EI PROF 7 11.000000 890.7800 80.9800
IPDEF-T1024TSTLGT-F/U PHYC AND DEV EVAL BY EI PROF 8 9.000000 728.8200 80.9800
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 59.500000 4818.3100 80.9800
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 174 235.000000 19030.3000 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 27 28.500000 2307.9300 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 88 110.500000 8948.2900 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 86 113.000000 6770.9600 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 272 445.000000 26664.4000 59.9200
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 65 113.000000 9150.7400 80.9800
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 153 242.000000 19597.1600 80.9800
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 87 87.000000 11671.4500 134.1546
OCTH-97165-OT EVAL LOW COMPLEXITY 16 16.000000 929.7600 58.1100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 116.2200 58.1100
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 13 13.000000 737.9800 56.7677
PSTH-97161GT-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97162-PT EVAL MODERATE 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 9 9.000000 522.9900 58.1100
SPCH-92522-EVAL OF SPCH SOUND PROD 4 4.000000 232.4400 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 450 1592.000000 119411.8900 75.0075
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 30 55.750000 2787.5000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 2 2.000000 100.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 2 2.000000 100.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 84 1984.500000 53581.5000 27.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1041 10178.00000 549612.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 66.250000 3577.5000 54.0000
EPIC-99601-Early Steps Professional Development Fee 878 8864.000000 132960.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 221 1650.000000 19800.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 51 203.500000 16548.6200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 44 226.000000 14741.4200 65.2275
PHY-97110-PT SESSION BY LICENSED PT 59 250.000000 20330.0000 81.3200
PHY-97110HM-PT SESSION BY PT ASST 32 202.500000 13175.6800 65.0651
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 80 318.500000 25900.4200 81.3200
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 11 55.000000 3581.6000 65.1200
Subtotal (Total Children Is Unduplicated) 1202 24060.00000 856896.2400 35.6150
-----------------------------------------------------------------------------------------------------------------------
Total 31763.250000 1203646.6300 37.8943
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1775
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 138 227.250000 8453.7000 0.0000
U 0 0.000000 0.0000 0.0000
B 1825 2913.750000 118277.5900 0.0000
P 13557 13752.750000 322777.5300 322775.1200
D 34 58.250000 2311.2600 0.0000
S 1 3.000000 111.6000 0.0000
H 8232 8148.000000 445790.2400 219.0000
T 0 0.000000 0.0000 0.0000
5055 6322.750000 280139.2000 90.0000
Other 612 337.500000 25785.5100 -120.0000
---------------------------------------------------------
Total 29454 31763.250000 1203646.6300 322964.1200