CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 405 261.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 545 895.250000 33031.7500 36.8967
Subtotal (Total Children Is Unduplicated) 545 1156.500000 33031.7500 28.5618
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 19 37.250000 1862.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 34.000000 2550.0000 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 10 16.500000 1237.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 47.500000 2636.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 230 353.000000 26475.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 67 99.500000 7425.0000 74.6231
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 192 342.500000 25687.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 48 67.000000 5025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 24 47.500000 3562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 416 681.000000 37740.0000 55.4185
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 102 140.000000 7714.5000 55.1036
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 12.000000 600.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 6 71.000000 3550.0000 50.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 5.000000 255.2500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 633 1989.750000 128666.6500 64.6647
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 47 62.500000 3125.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 8 13.500000 675.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 28 32.000000 800.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 15 15.000000 750.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 4 4.000000 200.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 17 18.000000 900.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 32 35.000000 1750.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 4 4.000000 200.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 42 898.250000 22456.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 550 3695.500000 184326.0100 49.8785
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 128 552.000000 27600.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 147 436.000000 4360.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 109 693.000000 49507.9200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 13 50.500000 3607.7200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 42 164.250000 9395.1000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 124 942.250000 67200.0200 71.3187
PHY-97110GT-PT SESSION BY LICENSED PT 14 64.500000 4607.8800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 25 92.750000 5301.5900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 382 3647.750000 260547.3200 71.4269
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 84 365.250000 26093.4600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 37 146.500000 8379.8000 57.2000
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
TRAV-TRAVS-Travel by mile 1634 150337.0000 65557.8900 0.4361
Subtotal (Total Children Is Unduplicated) 2154 162282.0000 748067.8600 4.6097
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Total 165428.250000 909766.2600 5.4995
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Number of Children (Unduplicated) With at Least One Service 2645
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Center 04
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
54 692.000000 17300.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 54 692.000000 17300.0000 0.0000
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
446 444.750000 24324.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 446 444.750000 24324.5600 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 7772 158213.750000 632876.3200 632876.3200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1840 2570.500000 130367.7500 0.0000
T 0 0.000000 0.0000 0.0000
129 1372.000000 19627.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9741 162156.250000 782871.2900 632876.3200
Center 10
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
1 0.500000 35.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.500000 35.7200 0.0000
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 2 3.000000 100.0000 100.0000
119 421.750000 5331.8300 408.1300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 121 424.750000 5431.8300 508.1300
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 7.250000 240.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 157 151.250000 10538.8300 10538.8300
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
430 415.250000 26265.5100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 594 573.750000 37044.8400 10538.8300
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 2 1.000000 71.4400 71.4400
H 0 0.000000 0.0000 0.0000
T 59 -197.500000 -9919.2500 -9919.2500
224 613.000000 29535.7400 29235.7400
Other 581 719.750000 23070.0900 23070.0900
---------------------------------------------------------
Total 866 1136.250000 42758.0200 42458.0200