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: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 5 5.000000 290.5500 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 156.8800 52.2933
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 8 9.000000 505.5400 56.1711
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 11 33.500000 2724.2200 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 3 22.000000 1432.6400 65.1200
PHY-97110-PT SESSION BY LICENSED PT 5 27.000000 2195.6400 81.3200
PHY-97110HM-PT SESSION BY PT ASST 1 1.500000 97.6800 65.1200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 66.000000 5367.1200 81.3200
Subtotal (Total Children Is Unduplicated) 26 150.000000 11817.3000 78.7820
-----------------------------------------------------------------------------------------------------------------------
Total 159.000000 12322.8400 77.5021
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 27
-----------------------------------------------------------------------------------------------------------------------
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 24 16.500000 1171.6800 1171.6800
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
0 0.000000 0.0000 0.0000
Other 256 138.500000 10890.6800 0.0000
---------------------------------------------------------
Total 284 159.000000 12322.8400 1171.6800