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: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 5 5.000000 257.0500 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 24 23.167089 1191.0200 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 10.000000 514.1000 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 3.000000 158.7900 52.9300
Subtotal (Total Children Is Unduplicated) 43 46.167089 2378.0100 51.5088
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 36 203.195528 14621.9500 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 5 39.000000 2246.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 5 12.386882 891.3600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 2 16.000000 920.9600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 59 343.262091 24701.1400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 359.8000 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 172.8000 57.6000
Subtotal (Total Children Is Unduplicated) 105 629.844501 44380.2900 70.4623
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Total 676.011590 46758.3000 69.1679
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Number of Children (Unduplicated) With at Least One Service 125
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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 0 0.000000 0.0000 0.0000
P 21 22.413243 1558.3300 1558.3300
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 95 246.598347 17114.8100 17114.8100
154 407.000000 28085.1600 28085.1600
Other 0 0.000000 0.0000 0.0000
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Total 270 676.011590 46758.3000 46758.3000