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: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 72 80.250000 2969.2500 37.0000
Subtotal (Total Children Is Unduplicated) 72 80.250000 2969.2500 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 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 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 25 25.000000 1276.2500 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 796 4899.000000 244950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 44 150.500000 7525.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 65.500000 4679.3200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 16 76.000000 4347.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 5 16.500000 1178.7600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 16 115.000000 6573.4000 57.1600
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.500000 178.6000 71.4400
Subtotal (Total Children Is Unduplicated) 854 5326.000000 269489.4400 50.5988
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Total 5431.250000 273734.9400 50.4000
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Number of Children (Unduplicated) With at Least One Service 922
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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 1 0.500000 35.7200 0.0000
D 1 1.500000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1604 5350.500000 270729.9700 0.0000
T 0 0.000000 0.0000 0.0000
8 7.250000 268.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1708 5431.250000 273734.9400 0.0000