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: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 61 74.750000 2765.7500 37.0000
Subtotal (Total Children Is Unduplicated) 61 74.750000 2765.7500 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 10 10.000000 510.5000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 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 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 22 22.000000 1123.1000 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 868 7839.500000 391975.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 52 222.000000 11100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 51.000000 3643.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 22 174.500000 9981.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 25.500000 1821.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 22 188.000000 10746.0800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 14.500000 1035.8800 71.4400
Subtotal (Total Children Is Unduplicated) 925 8517.000000 430417.9200 50.5363
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Total 8613.750000 434306.7700 50.4202
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Number of Children (Unduplicated) With at Least One Service 984
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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 35 42.500000 2137.5900 899.1000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2371 8522.000000 430346.9300 0.0000
T 0 0.000000 0.0000 0.0000
12 9.500000 351.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2466 8613.750000 434306.7700 899.1000