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: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
OCTH-97165-OT EVAL LOW COMPLEXITY 9 9.000000 386.1300 42.9033
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 9 9.000000 462.6900 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 7 7.000000 359.8700 51.4100
Subtotal (Total Children Is Unduplicated) 24 29.000000 1414.3300 48.7700
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 24 95.500000 6699.8000 70.1550
OCCT-97530HM-OT SESSION BY OT ASST 3 18.000000 1036.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 22 96.500000 6559.1400 67.9704
PHY-97110HM-PT SESSION BY PT ASST 13 16.250000 935.3500 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 80.250000 5774.7900 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 35.9800 71.9600
Subtotal (Total Children Is Unduplicated) 66 307.000000 21041.8600 68.5403
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Total 336.000000 22456.1900 66.8339
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Number of Children (Unduplicated) With at Least One Service 72
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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 35 77.000000 4703.6700 3084.5700
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
20 17.500000 1097.3000 831.0800
Other 122 241.500000 16655.2200 604.4400
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Total 177 336.000000 22456.1900 4520.0900