CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2025 ending 06/30/2025 Date of Report:07/19/2025 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 6 11.500000 427.8000 37.2000
Subtotal (Total Children Is Unduplicated) 6 11.500000 427.8000 37.2000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 16 32.000000 1600.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 283.4300 80.9800
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 242.9400 80.9800
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.500000 269.6400 59.9200
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 161.9600 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 119.8400 59.9200
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 3.000000 174.3300 58.1100
Subtotal (Total Children Is Unduplicated) 26 58.000000 3412.1200 58.8297
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 16 23.000000 1150.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 2.000000 50.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 5.000000 250.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 129 500.500000 27027.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 280 1249.000000 8022.0000 6.4227
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 15 73.000000 876.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 33 157.000000 12767.2400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 6 24.000000 1562.8800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 70 368.000000 29925.7600 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 5.000000 325.6000 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 92 408.000000 33178.5600 81.3200
TRAV-TRAVS-Travel by mile 332 15916.00000 7078.1000 0.4447
Subtotal (Total Children Is Unduplicated) 383 18733.50000 122363.1400 6.5318
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Total 18803.000000 126203.0600 6.7119
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Number of Children (Unduplicated) With at Least One Service 399
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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 4289 18661.000000 122594.2200 122594.2200
D 31 105.500000 1371.7100 0.0000
S 0 0.000000 0.0000 0.0000
H 15 25.500000 1555.9700 0.0000
T 0 0.000000 0.0000 0.0000
9 11.000000 681.1600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4344 18803.000000 126203.0600 122594.2200