CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2024 ending 06/30/2025 Date of Report:07/19/2025 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 134 393.250000 14628.9000 37.2000
Subtotal (Total Children Is Unduplicated) 134 393.250000 14628.9000 37.2000
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Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 18 23.000000 1316.4300 57.2361
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 2 2.000000 109.5200 54.7600
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 7 9.000000 522.9900 58.1100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 4 6.000000 341.9600 56.9933
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 109.5200 54.7600
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 10 12.000000 690.6200 57.5517
SPCH-92521TL-EVAL OF SPEECH FLUENCY 6 6.000000 321.8600 53.6433
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 44 71.000000 4005.2100 56.4114
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 897 24062.00000 1266344.0000 52.6284
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 13 153.000000 8126.0000 53.1111
OCCT-97530-OT SESSION BY LICENSED OT 26 380.500000 29954.7800 78.7248
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 81.3200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 19 249.000000 15435.5400 61.9901
PHY-97110-PT SESSION BY LICENSED PT 14 114.500000 9039.7000 78.9493
PHY-97110HM-PT SESSION BY PT ASST 20 337.500000 21312.9400 63.1495
PHY-97110TL-PT SESSION BY LICENSED PT 2 16.000000 1254.3200 78.3950
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 18.500000 1457.6200 78.7903
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 919 25334.00000 1353150.1400 53.4124
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Total 25798.250000 1371784.2500 53.1735
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Number of Children (Unduplicated) With at Least One Service 1019
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Center 04
Flag Claims Units Chgs Paid
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R 41 45.750000 1701.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 112 102.250000 3803.7000 0.0000
P 475 337.000000 15814.8000 9288.7700
D 0 0.000000 0.0000 0.0000
S 1 3.000000 111.6000 0.0000
H 25445 25255.000000 1347341.8000 216.0000
T 0 0.000000 0.0000 0.0000
66 51.750000 2840.8100 0.0000
Other 3 3.500000 169.6400 0.0000
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Total 26143 25798.250000 1371784.2500 9504.7700