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: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 1 1.000000 17.7800 17.7800
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 58.1100 58.1100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 58.1100 58.1100
Subtotal (Total Children Is Unduplicated) 3 3.000000 134.0000 44.6667
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 3 11.000000 754.5200 68.5927
OCCT-97530HM-OT SESSION BY OT ASST 1 5.000000 325.6000 65.1200
PHY-97110HM-PT SESSION BY PT ASST 1 8.000000 520.9600 65.1200
Subtotal (Total Children Is Unduplicated) 5 24.000000 1601.0800 66.7117
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Total 27.000000 1735.0800 64.2622
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Number of Children (Unduplicated) With at Least One Service 6
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Center 04
Flag Claims Units Chgs Paid
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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 4 4.000000 121.7400 121.7400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 1.000000 58.1100 0.0000
Other 22 22.000000 1555.2300 0.0000
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Total 27 27.000000 1735.0800 121.7400