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
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 2 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 232 475.750000 17602.7500 37.0000
Subtotal (Total Children Is Unduplicated) 232 476.250000 17621.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 3 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
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 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 69 111.500000 8362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 62 98.500000 7387.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1200.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 90 143.000000 7936.5000 55.5000
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) 144 417.000000 27703.8500 66.4361
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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 198 997.000000 48809.0800 48.9559
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 136 931.250000 66528.5000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 19 98.750000 7054.7000 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) 760 46704.25000 203768.5100 4.3630
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Total 47597.500000 249093.6100 5.2333
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Number of Children (Unduplicated) With at Least One Service 977
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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 1947 46204.750000 172602.4700 172602.4700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 333 525.000000 29724.0000 0.0000
T 0 0.000000 0.0000 0.0000
241 210.250000 7779.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2521 46940.000000 210105.7200 172602.4700
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 363 371.500000 25636.4100 25636.4100
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
205 187.000000 10084.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 568 558.500000 35721.0200 25636.4100
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
11 10.750000 397.7500 0.0000
Other 30 55.000000 1267.0400 1267.0400
---------------------------------------------------------
Total 41 65.750000 1664.7900 1267.0400