CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 09/30/2024 Date of Report:04/06/2025 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 97 117.000000 4352.4000 37.2000
Subtotal (Total Children Is Unduplicated) 97 117.000000 4352.4000 37.2000
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Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 321.8600 53.6433
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 58.1100 58.1100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 23 24.000000 1267.3400 52.8058
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 867 8523.000000 426870.0000 50.0845
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 46.000000 2364.0000 51.3913
OCCT-97530-OT SESSION BY LICENSED OT 19 112.000000 8115.6800 72.4614
OCCT-97530HM-OT SESSION BY OT ASST 16 114.500000 6676.9000 58.3135
PHY-97110-PT SESSION BY LICENSED PT 11 41.500000 3103.3400 74.7793
PHY-97110HM-PT SESSION BY PT ASST 17 99.500000 5825.5000 58.5477
PHY-97110TL-PT SESSION BY LICENSED PT 1 14.000000 1091.6800 77.9771
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 6.500000 481.7800 74.1200
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 889 8959.000000 454672.8000 50.7504
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Total 9100.000000 460292.5400 50.5816
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Number of Children (Unduplicated) With at Least One Service 969
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Center 04
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 14 12.250000 455.7000 0.0000
P 174 149.250000 6782.1100 3962.0200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8966 8907.000000 451221.6700 0.0000
T 0 0.000000 0.0000 0.0000
45 31.000000 1797.0800 0.0000
Other 1 0.500000 35.9800 0.0000
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Total 9200 9100.000000 460292.5400 3962.0200