CMS/EIP Fiscal Report Center: 57
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 10 14.750000 548.7000 37.2000
Subtotal (Total Children Is Unduplicated) 10 14.750000 548.7000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
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
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 12.000000 863.5200 71.9600
Subtotal (Total Children Is Unduplicated) 12 26.000000 1583.2600 60.8946
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 734 5031.000000 251550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 27 112.000000 5404.0000 48.2500
OCCT-97530-OT SESSION BY LICENSED OT 27 169.750000 12215.2100 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 17.000000 979.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 3 14.000000 1007.4400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 15 129.750000 7468.4100 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 111.500000 8023.5400 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 16 72.750000 4132.8000 56.8082
Subtotal (Total Children Is Unduplicated) 784 5661.750000 291068.4400 51.4096
-----------------------------------------------------------------------------------------------------------------------
Total 5702.500000 293200.4000 51.4161
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 789
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 0.500000 18.6000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.250000 83.7000 83.7000
T 0 0.000000 0.0000 0.0000
4265 5699.750000 293098.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4268 5702.500000 293200.4000 83.7000