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: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
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 308.4600 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 174.7800 58.2600
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 15 15.000000 791.7000 52.7800
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.000000 400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 104.000000 7483.8400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 33.000000 1900.8000 57.6000
PHY-97110HM-PT SESSION BY PT ASST 1 4.000000 230.2400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 97.000000 6980.1200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 7.000000 503.7200 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 54.750000 3153.6000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 4.000000 230.4000 57.6000
Subtotal (Total Children Is Unduplicated) 53 311.750000 20882.7200 66.9855
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Total 326.750000 21674.4200 66.3333
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Number of Children (Unduplicated) With at Least One Service 55
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Center 57
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 11 8.104924 569.2400 0.0000
D 14 14.540857 960.2000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 48 58.000000 3859.7400 3859.7400
222 246.104219 16285.2400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 295 326.750000 21674.4200 3859.7400