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: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
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 232.4400 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 174.3300 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 6 6.000000 348.6600 58.1100
Subtotal (Total Children Is Unduplicated) 11 14.000000 813.5400 58.1100
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 9 15.000000 1219.8000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 4 12.000000 781.4400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 5 9.000000 731.8800 81.3200
PHY-97110HM-PT SESSION BY PT ASST 2 7.000000 455.8400 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 22.000000 1789.0400 81.3200
Subtotal (Total Children Is Unduplicated) 22 65.000000 4978.0000 76.5846
-----------------------------------------------------------------------------------------------------------------------
Total 79.000000 5791.5400 73.3106
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 24
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 14 13.000000 871.9500 871.9500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 4.000000 260.4800 0.0000
T 0 0.000000 0.0000 0.0000
1 1.000000 58.1100 0.0000
Other 100 61.000000 4601.0000 0.0000
---------------------------------------------------------
Total 119 79.000000 5791.5400 871.9500