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
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 11 4.500000 166.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 16 17.000000 629.0000 37.0000
Subtotal (Total Children Is Unduplicated) 24 21.500000 795.5000 37.0000
-----------------------------------------------------------------------------------------------------------------------
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 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 6 7.000000 357.3500 51.0500
-----------------------------------------------------------------------------------------------------------------------
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 181 1565.750000 78287.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 77.750000 3887.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1016 9475.000000 94750.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 28.000000 2000.3200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 7 41.750000 2388.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 5.000000 357.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 29.000000 1657.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 29.500000 2107.4800 71.4400
Subtotal (Total Children Is Unduplicated) 1070 11301.50000 187923.2400 16.6282
-----------------------------------------------------------------------------------------------------------------------
Total 11330.000000 189076.0900 16.6881
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1082
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 3138 11234.500000 186908.8700 186898.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 43.000000 430.0000 430.0000
T 0 0.000000 0.0000 0.0000
32 21.500000 795.5000 0.0000
Other 11 31.000000 941.7200 941.7200
---------------------------------------------------------
Total 3193 11330.000000 189076.0900 188270.5900