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: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
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 308.4600 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 108.9100 36.3033
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 9 10.000000 514.1000 51.4100
Subtotal (Total Children Is Unduplicated) 22 26.000000 1291.3400 49.6669
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 20 78.000000 5568.7800 71.3946
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 12 53.000000 3358.4300 63.3666
PHY-97110HM-PT SESSION BY PT ASST 1 5.000000 287.8000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 57.500000 4137.7000 71.9600
Subtotal (Total Children Is Unduplicated) 34 194.500000 13410.3100 68.9476
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Total 220.500000 14701.6500 66.6741
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Number of Children (Unduplicated) With at Least One Service 36
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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 75 141.500000 9184.2100 4815.1300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 27.8600 27.8600
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 38 78.000000 5489.5800 0.0000
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Total 114 220.500000 14701.6500 4842.9900