CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Agency Filter:EXT
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 28 19.750000 730.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 72 92.000000 3367.0000 36.5978
Subtotal (Total Children Is Unduplicated) 89 111.750000 4097.7500 36.6689
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Screening, Eval, and Assessment,Class #02
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 16 16.000000 816.8000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 36 38.000000 1939.9000 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 810 5673.000000 283650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 167 933.750000 46687.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 811 5864.000000 58640.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 35 177.000000 12594.8800 71.1575
OCCT-97530GT-OT SESSION BY LICENSED OT 2 8.000000 571.5200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 43 228.000000 13041.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 4 23.750000 1358.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 27 156.000000 11022.2800 70.6556
PHY-97110HM-PT SESSION BY PT ASST 24 136.000000 7773.7600 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 105.500000 6835.3200 64.7898
Subtotal (Total Children Is Unduplicated) 1009 13308.00000 442346.8400 33.2392
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Total 13457.750000 448384.4900 33.3179
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Number of Children (Unduplicated) With at Least One Service 1093
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Center 04
Flag Claims Units Chgs Paid
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R 12 12.000000 444.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 59 48.750000 1766.7500 0.0000
P 1991 7241.000000 132803.1900 127854.1400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1615 5884.000000 297373.2700 870.0800
T 0 0.000000 0.0000 0.0000
66 47.500000 1822.5000 0.0000
Other 87 224.500000 14174.7800 1657.2800
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Total 3830 13457.750000 448384.4900 130381.5000