CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 3 1.000000 37.2000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 25 30.750000 1143.9000 37.2000
Subtotal (Total Children Is Unduplicated) 28 31.750000 1181.1000 37.2000
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Screening, Eval, and Assessment,Class #02
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 3 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 6 6.000000 308.4600 51.4100
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 17 30.750000 1537.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.500000 25.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 242 2276.000000 113750.0000 49.9780
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 25 97.000000 4800.0000 49.4845
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1080 10591.00000 105852.0000 9.9945
OCCT-97530-OT SESSION BY LICENSED OT 4 19.000000 1367.2400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 2 12.000000 691.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 7 27.500000 1978.9000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 5 32.000000 1841.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 36.000000 2590.5600 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 115.2000 57.6000
Subtotal (Total Children Is Unduplicated) 1120 13127.75000 234749.5200 17.8819
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Total 13165.500000 236239.0800 17.9438
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Number of Children (Unduplicated) With at Least One Service 1142
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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 3413 13111.750000 234355.7800 234303.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 19.000000 620.2400 230.0000
T 0 0.000000 0.0000 0.0000
43 33.750000 1191.1000 0.0000
Other 1 1.000000 71.9600 71.9600
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Total 3463 13165.500000 236239.0800 234605.7400