CMS/EIP Fiscal Report Center: 57
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 7 13.500000 502.2000 37.2000
Subtotal (Total Children Is Unduplicated) 7 13.500000 502.2000 37.2000
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Screening, Eval, and Assessment,Class #02
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 2 2.000000 102.8200 51.4100
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 20 214.000000 5520.0000 25.7944
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 26 248.000000 13012.0000 52.4677
EPIC-99601-Early Steps Professional Development Fee 1 1.000000 15.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 4.000000 48.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 86.500000 6307.3200 72.9170
OCCT-97530HM-OT SESSION BY OT ASST 10 27.000000 1526.4000 56.5333
PHY-97110-PT SESSION BY LICENSED PT 6 18.000000 1259.3000 69.9611
PHY-97110HM-PT SESSION BY PT ASST 13 39.000000 2244.8400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 35.000000 2556.0400 73.0297
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 23 63.500000 3600.0000 56.6929
Subtotal (Total Children Is Unduplicated) 82 737.000000 36138.9000 49.0351
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Total 752.500000 36743.9200 48.8291
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Number of Children (Unduplicated) With at Least One Service 86
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Center 57
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 2 2.000000 104.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
849 747.250000 36519.0200 0.0000
Other 3 3.250000 120.9000 0.0000
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Total 854 752.500000 36743.9200 0.0000