CMS/EIP Fiscal Report Center: 57
Services beginning 04/01/2025 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 220 122.250000 4547.7000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 216 627.500000 23370.9000 37.2445
Subtotal (Total Children Is Unduplicated) 375 749.750000 27918.6000 37.2372
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 2 4.000000 200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 80.9800 80.9800
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 89.8800 59.9200
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 283.4300 80.9800
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 209.7200 59.9200
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 116.2200 58.1100
Subtotal (Total Children Is Unduplicated) 8 16.500000 1038.3400 62.9297
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 4.750000 237.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 42 44.000000 2200.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 17 17.000000 850.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 2 3.000000 150.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 76 78.000000 3900.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 71 71.000000 3550.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 221 2298.000000 124092.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 5 14.000000 756.0000 54.0000
EPIC-99601-Early Steps Professional Development Fee 492 5023.000000 75345.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 120 1075.000000 12924.0000 12.0223
OCCT-97530-OT SESSION BY LICENSED OT 3 24.000000 1951.6800 81.3200
PHY-97110-PT SESSION BY LICENSED PT 5 17.500000 1423.1000 81.3200
PHY-97110GPGT-PT SESSION BY LICENSED PT 3 3.000000 243.9600 81.3200
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 162.6400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 2 14.000000 911.6800 65.1200
TRAV-TRAVS-Travel by mile 4 1842.000000 819.6600 0.4450
Subtotal (Total Children Is Unduplicated) 596 10533.25000 229667.2200 21.8040
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Total 11299.500000 258624.1600 22.8881
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Number of Children (Unduplicated) With at Least One Service 711
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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 119 124.500000 3154.6000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 6642 8455.750000 174196.7100 174196.7100
2743 2719.250000 81272.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9504 11299.500000 258624.1600 174196.7100