CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 168 280.000000 10360.0000 37.0000
Subtotal (Total Children Is Unduplicated) 168 280.000000 10360.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 8.500000 637.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 69 104.000000 7800.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 62 105.000000 7875.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 123 192.500000 10683.7500 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 157 468.500000 30495.1000 65.0909
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.000000 100.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 9 11.000000 550.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 8 8.000000 200.0000 25.0000
CONIP-CONIP-CONSULT, ITDS PHONE 2 3.000000 75.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.750000 87.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 7 6.500000 325.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 3 2.500000 125.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 5 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 71 260.000000 13000.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 13 55.750000 2787.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 8 15.000000 150.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 42 161.500000 11537.5600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 11.000000 785.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 9 45.000000 2574.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 48 202.500000 14466.6000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 6 24.750000 1768.1400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 21.000000 1200.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 136 587.000000 41877.7200 71.3419
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 18 69.000000 4929.3600 71.4400
TRAV-TRAVS-Travel by mile 220 9468.000000 4173.5900 0.4408
Subtotal (Total Children Is Unduplicated) 425 10962.25000 101070.3700 9.2199
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Total 11710.750000 141925.4700 12.1192
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Number of Children (Unduplicated) With at Least One Service 598
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Center 05
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 1 2.000000 20.0000 20.0000
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 1 2.000000 20.0000 20.0000
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
33 28.500000 1732.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 33 28.500000 1732.5600 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 510 10408.750000 65124.0100 65124.0100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 393 613.000000 34226.0000 0.0000
T 0 0.000000 0.0000 0.0000
38 137.500000 9158.3600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 941 11159.250000 108508.3700 65124.0100
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 1 1.000000 50.0000 50.0000
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 1 1.000000 50.0000 50.0000
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 1 1.000000 50.0000 50.0000
8 9.750000 411.3800 95.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 10.750000 461.3800 145.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.250000 9.2500 0.0000
P 314 317.000000 21550.3700 21550.3700
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 97.500000 6099.2400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 408 414.750000 27658.8600 21550.3700
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 2 3.000000 195.7500 195.7500
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
44 61.750000 2284.7500 0.0000
Other 21 29.750000 1013.8000 1013.8000
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Total 67 94.500000 3494.3000 1209.5500