CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 2 4.000000 148.8000 37.2000
Subtotal (Total Children Is Unduplicated) 2 4.000000 148.8000 37.2000
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Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 9 9.000000 462.6900 51.4100
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 13.000000 325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 711 5116.000000 255800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 45 212.500000 10625.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 38.000000 2734.4800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 17.000000 979.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 4 38.000000 2734.4800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 3 18.000000 1036.0800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 61.000000 4389.5600 71.9600
Subtotal (Total Children Is Unduplicated) 745 5513.500000 278623.8000 50.5348
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Total 5526.500000 279235.2900 50.5266
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Number of Children (Unduplicated) With at Least One Service 747
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Center 57
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 1 1.250000 46.5000 0.0000
P 13 25.750000 1644.4800 1644.4800
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
1511 5499.500000 277544.3100 277544.3100
Other 0 0.000000 0.0000 0.0000
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Total 1525 5526.500000 279235.2900 279188.7900