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: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 57 69.250000 2525.2500 36.4657
Subtotal (Total Children Is Unduplicated) 57 69.250000 2525.2500 36.4657
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 15 15.000000 765.7500 51.0500
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 665 4766.000000 238300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 121 632.000000 31600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 54.000000 3857.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 29 159.500000 9123.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 13.000000 743.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 46.500000 3321.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 23 129.000000 7373.6400 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 5 15.000000 1071.6000 71.4400
Subtotal (Total Children Is Unduplicated) 790 5818.000000 295563.4400 50.8016
-----------------------------------------------------------------------------------------------------------------------
Total 5902.250000 298854.4400 50.6340
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 849
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 16 19.500000 1000.5000 414.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1595 5817.000000 295393.1900 0.0000
T 0 0.000000 0.0000 0.0000
1 5.000000 250.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1683 5902.250000 298854.4400 414.5000