CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 106 145.000000 5346.5000 36.8724
Subtotal (Total Children Is Unduplicated) 106 145.000000 5346.5000 36.8724
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 65 97.000000 7237.5000 74.6134
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 47 65.500000 4912.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 24 47.500000 3562.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 99 136.000000 7492.5000 55.0919
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 142 376.000000 25167.8000 66.9356
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 15.000000 750.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 8 13.500000 675.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 17 21.500000 537.5000 25.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 4 4.000000 200.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 4 4.000000 200.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 47.000000 1175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 275.000000 13750.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 114 493.000000 24650.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 40.750000 2911.1800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 9 39.500000 2821.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 22 72.750000 5197.2600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 14 51.500000 3679.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 4.750000 271.5100 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 72 317.750000 22700.0600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 68 284.500000 20324.6800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
TRAV-TRAVS-Travel by mile 104 5158.000000 2248.7800 0.4360
Subtotal (Total Children Is Unduplicated) 390 6853.500000 102723.6100 14.9885
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Total 7374.500000 133237.9100 18.0674
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Number of Children (Unduplicated) With at Least One Service 524
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Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
93 92.500000 4914.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 93 92.500000 4914.4400 0.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 448 5213.500000 68936.2000 68936.2000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 318 434.500000 24167.7500 0.0000
T 0 0.000000 0.0000 0.0000
113 1328.000000 16637.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 879 6976.000000 109741.4500 68936.2000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
18 17.500000 1070.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 18 17.500000 1070.8400 0.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 73 64.250000 4576.7500 4576.7500
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
163 151.250000 10459.4300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 236 215.500000 15036.1800 4576.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
7 61.000000 1875.0000 1575.0000
Other 8 12.000000 600.0000 600.0000
---------------------------------------------------------
Total 15 73.000000 2475.0000 2175.0000