CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 6 3.250000 120.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 90 101.500000 3755.5000 37.0000
Subtotal (Total Children Is Unduplicated) 91 104.750000 3875.7500 37.0000
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Screening, Eval, and Assessment,Class #02
NURS-T1001-NURSING ASSESSMENT 1 4.000000 200.0000 50.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162TLGT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 44 51.000000 2599.3500 50.9676
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 14 21.000000 1050.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 965 5939.000000 296950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 56 207.500000 10375.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 945 5965.000000 59650.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 126.250000 9019.3000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 21 103.000000 5891.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 22 61.500000 4309.5600 70.0741
PHY-97110HM-PT SESSION BY PT ASST 19 137.000000 7830.9200 57.1600
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 98.000000 7001.1200 71.4400
Subtotal (Total Children Is Unduplicated) 1089 12659.25000 402134.6600 31.7661
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Total 12815.000000 408609.7600 31.8853
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Number of Children (Unduplicated) With at Least One Service 1163
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Center 04
Flag Claims Units Chgs Paid
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R 1 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 93 68.500000 2534.5000 0.0000
P 2155 7210.750000 123877.3800 120905.6200
D 1 1.500000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1615 5378.500000 272573.1700 0.0000
T 0 0.000000 0.0000 0.0000
39 31.750000 1174.7500 0.0000
Other 61 121.000000 8283.4600 0.0000
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Total 3965 12815.000000 408609.7600 120905.6200