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
Payclass Filters:GR
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 15 22.750000 841.7500 37.0000
Subtotal (Total Children Is Unduplicated) 43 42.500000 1572.5000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1 1.000000 51.0500 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 147 885.000000 44250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 46 301.750000 15087.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 811 5864.000000 58640.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 22.000000 1258.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 10.750000 614.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 12.000000 857.2800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 7.000000 400.1200 57.1600
Subtotal (Total Children Is Unduplicated) 852 7106.500000 121393.9600 17.0821
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Total 7150.000000 123017.5100 17.2052
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Number of Children (Unduplicated) With at Least One Service 889
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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 1898 7036.500000 119704.9300 119704.9300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 14 45.000000 880.0800 870.0800
T 0 0.000000 0.0000 0.0000
65 42.500000 1572.5000 0.0000
Other 5 26.000000 860.0000 800.0000
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Total 1982 7150.000000 123017.5100 121375.0100