CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 4 6.500000 325.0000 50.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 13 17.500000 943.3500 53.9057
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 8 8.000000 400.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 8 12.500000 625.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 22 27.000000 675.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 4.000000 200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 161 954.000000 47700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 72 270.000000 13500.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 9.000000 90.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 49 272.500000 19467.4000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 13 71.000000 5072.2400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 6 40.000000 2288.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 65 485.500000 34684.1200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 7 29.000000 2071.7600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 13.500000 771.6600 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 6.000000 342.9600 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 143 917.500000 65546.2000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 24 139.000000 9930.1600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
TRAV-TRAVS-Travel by mile 405 30953.00000 13562.0400 0.4381
Subtotal (Total Children Is Unduplicated) 649 34231.25000 217976.8000 6.3678
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Total 34248.750000 218920.1500 6.3921
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Number of Children (Unduplicated) With at Least One Service 657
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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
33 30.500000 1607.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33 30.500000 1607.2000 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 1015 20416.500000 128981.0400 128981.0400
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 607 13473.500000 67834.4200 67834.4200
2 4.000000 200.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1624 33894.000000 197015.4600 196815.4600
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
11 11.500000 778.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11 11.500000 778.6800 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 230 239.250000 15290.1100 15290.1100
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
52 52.000000 3415.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 282 291.250000 18705.1500 15290.1100
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
0 0.000000 0.0000 0.0000
Other 12 21.500000 813.6600 813.6600
---------------------------------------------------------
Total 12 21.500000 813.6600 813.6600