CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 1.000000 37.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 177 484.750000 17917.2500 36.9618
Subtotal (Total Children Is Unduplicated) 177 485.750000 17954.2500 36.9619
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 4 8.000000 400.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 10.500000 582.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 49 74.000000 5587.5000 75.5068
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 61 111.500000 8362.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 83 132.500000 7353.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 5 13.000000 650.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 142 396.000000 26280.3000 66.3644
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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 17 22.250000 1112.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 23 30.000000 750.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 3 3.000000 150.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.750000 68.7500 25.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 5.000000 250.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 2 2.000000 100.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 166 972.500000 48675.0000 50.0514
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 82 412.000000 20600.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 10.000000 100.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 48 251.750000 17985.0200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 13 51.000000 3643.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 8 37.500000 2145.0000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 4 7.000000 500.0800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 52 397.000000 28361.6800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 39.000000 2786.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 25.000000 1429.0000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 138 1024.250000 72886.6600 71.1610
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 26 140.000000 10001.6000 71.4400
TRAV-TRAVS-Travel by mile 444 32334.00000 14202.6200 0.4392
Subtotal (Total Children Is Unduplicated) 695 35791.00000 226990.3900 6.3421
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Total 36672.750000 271224.9400 7.3958
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Number of Children (Unduplicated) With at Least One Service 882
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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
45 35.500000 2035.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 45 35.500000 2035.8800 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 1652 35298.750000 195700.6400 195700.6400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 267 423.000000 23655.0000 0.0000
T 0 0.000000 0.0000 0.0000
326 344.000000 12761.5000 0.0000
Other 1 2.000000 -142.8800 0.0000
---------------------------------------------------------
Total 2246 36067.750000 231974.2600 195700.6400
Center 51
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 2 2.000000 100.0000 100.0000
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 2.000000 100.0000 100.0000
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 1 1.000000 50.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
55 93.250000 5376.8700 3320.8400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 56 94.250000 5426.8700 3320.8400
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 279 281.500000 19141.8500 19141.8500
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
180 184.750000 12235.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 459 466.250000 31376.8800 19141.8500
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 7 7.000000 311.0500 311.0500
---------------------------------------------------------
Total 7 7.000000 311.0500 311.0500