CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 85 115.500000 4296.6000 37.2000
Subtotal (Total Children Is Unduplicated) 85 115.500000 4296.6000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 9 9.000000 462.6900 51.4100
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 754 5392.000000 269350.0000 49.9536
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 39 179.000000 8950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 68.000000 4838.3800 71.1526
OCCT-97530HM-OT SESSION BY OT ASST 8 44.000000 2534.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 6 24.500000 1763.0200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 10 54.000000 3102.0900 57.4461
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 8.500000 611.6600 71.9600
Subtotal (Total Children Is Unduplicated) 811 5770.000000 291149.5500 50.4592
-----------------------------------------------------------------------------------------------------------------------
Total 5894.500000 295908.8400 50.2008
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 895
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 14 13.000000 483.6000 0.0000
P 10 20.250000 1251.8000 132.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1557 5761.500000 290462.7400 100.0000
T 0 0.000000 0.0000 0.0000
118 99.500000 3701.4000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1700 5894.500000 295908.8400 232.2500