CMS/EIP Fiscal Report Center: 57
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 2 1.250000 46.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2 1.250000 46.2500 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 13 19.000000 963.4500 50.7079
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 563 3741.000000 187050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 46 197.500000 9875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 7.000000 500.0800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 3.000000 214.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.500000 107.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 29.000000 1657.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
Subtotal (Total Children Is Unduplicated) 600 3985.000000 199818.6000 50.1427
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Total 4005.250000 200828.3000 50.1413
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Number of Children (Unduplicated) With at Least One Service 609
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Center 57
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 0 0.000000 0.0000 0.0000
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
1135 4005.250000 200828.3000 200788.5500
Other 0 0.000000 0.0000 0.0000
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Total 1135 4005.250000 200828.3000 200788.5500