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
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 6 3.250000 120.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 18 21.250000 786.2500 37.0000
Subtotal (Total Children Is Unduplicated) 23 24.500000 906.5000 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 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 6 9.000000 455.2500 50.5833
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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 168 1035.000000 51750.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 11 56.000000 2800.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 945 5965.000000 59650.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 17.250000 1232.3400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 20.000000 1144.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 16.000000 914.5600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 214.3200 71.4400
Subtotal (Total Children Is Unduplicated) 980 7136.250000 118969.5400 16.6712
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Total 7169.750000 120331.2900 16.7832
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Number of Children (Unduplicated) With at Least One Service 999
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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 0 0.000000 0.0000 0.0000
P 2119 7145.250000 119424.7900 119264.7900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 24.500000 906.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2150 7169.750000 120331.2900 119264.7900