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: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 7 7.000000 359.8700 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 9 9.000000 462.6900 51.4100
Subtotal (Total Children Is Unduplicated) 23 25.000000 1285.2500 51.4100
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 23 96.500000 6944.1400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 7.000000 200.3200 28.6171
PHY-97110-PT SESSION BY LICENSED PT 21 80.500000 5792.7800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 2 13.000000 748.2800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 144.500000 10398.2200 71.9600
Subtotal (Total Children Is Unduplicated) 59 341.500000 24083.7400 70.5234
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Total 366.500000 25368.9900 69.2196
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Number of Children (Unduplicated) With at Least One Service 61
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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 34 71.000000 4596.0600 3976.1900
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
1 3.500000 251.8600 0.0000
Other 136 292.000000 20521.0700 555.1300
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Total 171 366.500000 25368.9900 4531.3200