CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 2 4.000000 200.0000 50.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 2.000000 100.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 28 45.000000 2817.8500 62.6189
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 12.250000 612.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 21 36.000000 1800.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 31 34.000000 850.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.000000 150.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 3.500000 175.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 2 1.750000 68.7500 39.2857
CONPP-CONPP-CONSULT, PT, PHONE 5 6.000000 150.0000 25.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 12 17.000000 850.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 197 993.000000 48609.0800 48.9517
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 37.000000 1850.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 19 43.000000 430.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 55 245.500000 17538.5200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 5.000000 357.2000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 9 35.000000 2002.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 66 393.000000 28075.9200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 67.000000 4786.4800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 6 34.250000 1957.7300 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 134 929.250000 66385.6200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 18 98.000000 7001.1200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
TRAV-TRAVS-Travel by mile 552 43696.00000 19279.2500 0.4412
Subtotal (Total Children Is Unduplicated) 756 46697.50000 203372.0500 4.3551
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Total 46742.500000 206189.9000 4.4112
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Number of Children (Unduplicated) With at Least One Service 768
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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
4 4.000000 200.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 4.000000 200.0000 0.0000
Center 07
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 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 1 2.000000 100.0000 100.0000
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 1946 46202.750000 172452.4700 172452.4700
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 1946 46202.750000 172452.4700 172452.4700
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 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
2 2.000000 128.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 4.000000 228.6400 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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
22 23.250000 1073.4400 18.7500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 22 23.250000 1073.4400 18.7500
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 362 369.500000 25486.4100 25486.4100
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
80 82.000000 5381.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 442 451.500000 30868.3100 25486.4100
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 30 55.000000 1267.0400 1267.0400
---------------------------------------------------------
Total 30 55.000000 1267.0400 1267.0400