CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2025 ending 03/31/2025 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 91 101.750000 3785.1000 37.2000
Subtotal (Total Children Is Unduplicated) 91 101.750000 3785.1000 37.2000
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Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 232.4400 58.1100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 116.2200 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 232.4400 58.1100
Subtotal (Total Children Is Unduplicated) 15 15.000000 871.6500 58.1100
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 685 4259.000000 229986.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 40.000000 2160.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 52.000000 4228.6400 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 5 16.000000 1041.9200 65.1200
PHY-97110-PT SESSION BY LICENSED PT 3 9.500000 772.5400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 11 62.000000 4037.4400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.500000 121.9800 81.3200
Subtotal (Total Children Is Unduplicated) 704 4440.000000 242348.5200 54.5830
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Total 4556.750000 247005.2700 54.2065
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Number of Children (Unduplicated) With at Least One Service 795
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Center 04
Flag Claims Units Chgs Paid
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R 19 19.000000 706.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 149 77.500000 2883.0000 0.0000
P 7 6.500000 309.0000 308.8000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4461 4446.000000 242713.6200 0.0000
T 0 0.000000 0.0000 0.0000
10 7.750000 392.8500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4646 4556.750000 247005.2700 308.8000