CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 82 140.250000 5189.2500 37.0000
Subtotal (Total Children Is Unduplicated) 82 140.250000 5189.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 2 4.000000 200.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 27 46.500000 3487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 37 63.000000 4725.0000 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 57 97.500000 5411.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 175.5000 50.1429
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 3.000000 150.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 1 2.000000 100.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 5.000000 255.2500 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 4 4.000000 201.6500 50.4125
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 91 261.500000 16928.9500 64.7379
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 13.000000 650.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 26 34.000000 1700.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 51 59.750000 1493.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 7.000000 350.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 4 9.000000 450.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 2.250000 112.5000 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 2 2.000000 100.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 2.000000 50.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 9.000000 450.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 12 13.000000 650.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 9 162.000000 4050.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 252 1409.000000 70450.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 26 82.000000 4100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 8 19.000000 190.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 94 492.250000 35166.3400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 22 82.750000 4733.3000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 92 475.000000 33934.0000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 82.500000 5893.8000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 13 47.500000 2715.1000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 221 1467.000000 104427.7300 71.1845
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 27 132.000000 9430.0800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 22 66.000000 3775.2000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 773 54137.00000 23766.5500 0.4390
Subtotal (Total Children Is Unduplicated) 1005 58815.00000 309224.1100 5.2576
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Total 59216.750000 331342.3100 5.5954
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Number of Children (Unduplicated) With at Least One Service 1073
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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
15 11.500000 692.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 11.500000 692.9200 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 2140 43529.000000 200600.3600 200600.3600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 171 286.500000 16015.7500 0.0000
T 0 0.000000 0.0000 0.0000
659 14510.500000 67305.2400 79.2500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2970 58326.000000 283921.3500 200679.6100
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 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
2 5.000000 357.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 5.000000 357.2000 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 2.000000 60.0000 60.0000
7 41.000000 581.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9 43.000000 641.5400 60.0000
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 311 314.500000 21512.2300 21512.2300
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
74 81.750000 5265.8200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 385 396.250000 26778.0500 21512.2300
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
154 412.750000 18397.7000 17389.4500
Other 14 22.250000 553.5500 553.5500
---------------------------------------------------------
Total 168 435.000000 18951.2500 17943.0000