CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 11 4.500000 166.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 77 91.750000 3394.7500 37.0000
Subtotal (Total Children Is Unduplicated) 79 96.250000 3561.2500 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.000000 381.0800 47.6350
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 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-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 6.000000 306.3000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 3 3.000000 133.6500 44.5500
Subtotal (Total Children Is Unduplicated) 49 50.000000 2505.6800 50.1136
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 31 49.750000 2487.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1045 9421.250000 471062.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 66 299.750000 14987.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1016 9475.000000 94750.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 39 176.000000 12332.4000 70.0705
OCCT-97530HM-OT SESSION BY OT ASST 34 234.250000 13399.1000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 25 134.000000 9332.0800 69.6424
PHY-97110HM-PT SESSION BY PT ASST 26 228.000000 13032.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 173.500000 12394.8400 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 57.2000 57.2000
Subtotal (Total Children Is Unduplicated) 1189 20194.50000 643950.0000 31.8874
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Total 20340.750000 650016.9300 31.9564
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Number of Children (Unduplicated) With at Least One Service 1240
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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 48 39.750000 1470.7500 0.0000
P 3245 11431.000000 199384.1500 191520.0700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2391 8594.000000 432448.6900 430.0000
T 0 0.000000 0.0000 0.0000
44 31.000000 1147.0000 0.0000
Other 99 245.000000 15566.3400 2020.4800
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Total 5827 20340.750000 650016.9300 193970.5500