CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2025 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 47 92.250000 3431.7000 37.2000
Subtotal (Total Children Is Unduplicated) 47 92.250000 3431.7000 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-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 2 2.000000 116.2200 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 174.3300 58.1100
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 11 12.000000 697.3200 58.1100
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 360 3746.000000 202284.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 25.000000 1350.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 55.000000 4472.6000 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 5 44.000000 2865.2800 65.1200
PHY-97110-PT SESSION BY LICENSED PT 4 17.500000 1423.1000 81.3200
PHY-97110HM-PT SESSION BY PT ASST 6 55.000000 3570.4800 64.9178
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.500000 284.6200 81.3200
Subtotal (Total Children Is Unduplicated) 373 3946.000000 216250.0800 54.8024
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Total 4050.250000 220379.1000 54.4112
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Number of Children (Unduplicated) With at Least One Service 421
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Center 04
Flag Claims Units Chgs Paid
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R 11 12.000000 446.4000 0.0000
U 0 0.000000 0.0000 0.0000
B 68 71.500000 2659.8000 0.0000
P 6 6.000000 307.2000 307.2000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3983 3950.000000 216503.0700 0.0000
T 0 0.000000 0.0000 0.0000
11 10.750000 462.6300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4079 4050.250000 220379.1000 307.2000