CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2024 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 2 1.000000 37.2000 37.2000
Subtotal (Total Children Is Unduplicated) 2 1.000000 37.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 196.7300 49.1825
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 3 5.000000 254.8400 50.9680
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EI Services,Class #03
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 1 0.500000 25.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 24.000000 1276.0000 53.1667
EPIC-99601-Early Steps Professional Development Fee 4 4.000000 60.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 8.000000 96.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110TL-PT SESSION BY LICENSED PT 1 0.750000 53.9700 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 81.3200 81.3200
TRAV-TRAVS-Travel by mile 11 240.000000 106.7400 0.4448
Subtotal (Total Children Is Unduplicated) 38 280.250000 1852.3100 6.6095
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Total 286.250000 2144.3500 7.4912
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Number of Children (Unduplicated) With at Least One Service 42
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Center 52
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 54.0000 54.0000
64 285.250000 2090.3500 402.7200
Other 0 0.000000 0.0000 0.0000
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Total 65 286.250000 2144.3500 456.7200