CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2025 ending 12/31/2025 Date of Report:01/07/2026 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 79 141.750000 6468.7800 45.6351
Subtotal (Total Children Is Unduplicated) 79 141.750000 6468.7800 45.6351
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Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 348.6600 58.1100
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 4 4.000000 232.4400 58.1100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 174.3300 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 702 4728.000000 255312.0000 54.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 35.000000 1890.0000 54.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 19.750000 1606.0700 81.3200
OCCT-97530HM-OT SESSION BY OT ASST 3 10.000000 651.2000 65.1200
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 81.3200 81.3200
PHY-97110HM-PT SESSION BY PT ASST 13 69.000000 4493.2800 65.1200
PHY-97110TLHM-PT SESSION BY PT ASST 1 6.000000 390.7200 65.1200
Subtotal (Total Children Is Unduplicated) 718 4868.750000 264424.5900 54.3106
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Total 5025.500000 271765.0200 54.0772
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Number of Children (Unduplicated) With at Least One Service 802
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Center 04
Flag Claims Units Chgs Paid
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R 23 24.500000 1119.1600 0.0000
U 0 0.000000 0.0000 0.0000
B 94 101.250000 4625.1000 0.0000
P 16 18.750000 975.8500 673.7800
D 1 0.750000 27.9000 0.0000
S 0 0.000000 0.0000 0.0000
H 4876 4875.750000 264754.7200 0.0000
T 0 0.000000 0.0000 0.0000
4 3.500000 197.1700 0.0000
Other 1 1.000000 65.1200 0.0000
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Total 5015 5025.500000 271765.0200 673.7800