CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 90 102.000000 3794.4000 37.2000
Subtotal (Total Children Is Unduplicated) 90 102.000000 3794.4000 37.2000
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Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 14 15.000000 771.1500 51.4100
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 810 5574.000000 278650.0000 49.9910
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 57.000000 2850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 46.000000 3310.1600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 21.000000 1209.6000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 5 24.000000 1639.2000 68.3000
PHY-97110HM-PT SESSION BY PT ASST 8 59.000000 3396.0400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.500000 179.9000 71.9600
Subtotal (Total Children Is Unduplicated) 831 5787.500000 291522.7400 50.3711
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Total 5904.500000 296088.2900 50.1462
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Number of Children (Unduplicated) With at Least One Service 914
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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 87 61.000000 2269.2000 0.0000
P 49 39.250000 1474.3100 1153.1500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1513 5796.500000 291985.4300 0.0000
T 0 0.000000 0.0000 0.0000
8 7.750000 359.3500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1657 5904.500000 296088.2900 1153.1500