CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 7 2.000000 74.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 605 1430.000000 52910.0000 37.0000
Subtotal (Total Children Is Unduplicated) 605 1432.000000 52984.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 8.000000 600.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 10.000000 555.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 103 173.500000 13012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 64 106.000000 7950.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 23.000000 1725.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 141 229.000000 12709.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 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) 194 584.000000 38722.8500 66.3063
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 25.000000 1250.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 21 35.000000 1750.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 25 28.500000 712.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 5.000000 250.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 3 5.000000 250.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 3.000000 150.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 5.000000 250.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 8.000000 400.0000 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 2 2.000000 100.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 8 13.000000 650.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 163 1028.000000 51400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 6 13.000000 650.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 11.000000 110.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 49 251.250000 17949.3000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 4.000000 285.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 8 29.750000 1701.7000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 68 403.000000 28504.5600 70.7309
PHY-97110GT-PT SESSION BY LICENSED PT 15 63.000000 4500.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 17.500000 1000.3000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 153 877.500000 62688.6000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 19 106.000000 7572.6400 71.4400
TRAV-TRAVS-Travel by mile 463 33433.00000 14691.5600 0.4394
Subtotal (Total Children Is Unduplicated) 668 36373.00000 197062.3400 5.4178
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Total 38389.000000 288769.1900 7.5222
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Number of Children (Unduplicated) With at Least One Service 1290
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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
8 7.000000 337.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8 7.000000 337.5000 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 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 256 132.500000 5015.5000 0.0000
---------------------------------------------------------
Total 256 132.500000 5015.5000 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 1 0.500000 18.5000 0.0000
P 1206 24697.000000 109440.4600 109440.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 300 459.500000 26777.0000 0.0000
T 0 0.000000 0.0000 0.0000
556 11178.000000 59831.9700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2063 36335.000000 196067.9300 109440.4600
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 78.000000 63.3700 63.3700
32 44.000000 2891.6000 2245.7600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 34 122.000000 2954.9700 2309.1300
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 313 316.750000 20992.4800 20992.4800
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
325 324.500000 16131.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 638 641.250000 37123.7900 20992.4800
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
594 1134.750000 46699.1500 142.9000
Other 8 16.500000 570.3500 487.1000
---------------------------------------------------------
Total 602 1151.250000 47269.5000 630.0000