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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 18 18.000000 945.4800 52.5267
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 13 13.000000 625.0300 48.0792
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 25 25.000000 1298.6500 51.9460
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 56 64.000000 3287.1400 51.3616
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 35 182.000000 12935.4900 71.0741
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 8 41.000000 2369.1200 57.7834
PHY-97110-PT SESSION BY LICENSED PT 30 124.500000 9267.9000 74.4410
PHY-97110HM-PT SESSION BY PT ASST 9 42.500000 2446.3000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 193.000000 14323.5200 74.2151
Subtotal (Total Children Is Unduplicated) 85 584.000000 41414.2900 70.9149
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Total 648.000000 44701.4300 68.9837
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Number of Children (Unduplicated) With at Least One Service 92
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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 0 0.000000 0.0000 0.0000
P 758 435.000000 30102.2300 9471.9200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 16 13.500000 937.4200 0.0000
T 0 0.000000 0.0000 0.0000
4 4.000000 205.6400 0.0000
Other 279 195.500000 13456.1400 0.0000
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Total 1057 648.000000 44701.4300 9471.9200