CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 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 1 0.750000 27.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 398 500.000000 18490.7500 36.9815
Subtotal (Total Children Is Unduplicated) 398 500.750000 18518.5000 36.9815
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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 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 86 138.000000 10350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 56 86.500000 6487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 120 181.000000 10045.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 176 496.500000 33090.0000 66.6465
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 4 4.000000 200.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 6 6.000000 150.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.500000 75.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 6 6.000000 300.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 26 252.000000 6300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 62 322.000000 16100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 19.000000 950.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 23 57.200000 572.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 44 204.750000 14627.3400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 11 86.000000 4919.2000 57.2000
OCCT-97530TLGTHM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 25 130.000000 9287.2000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 3 11.000000 785.8400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 6 28.000000 1600.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 123 606.250000 43310.5000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 29.500000 2107.4800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
TRAV-TRAVS-Travel by mile 153 6168.000000 2715.0100 0.4402
Subtotal (Total Children Is Unduplicated) 398 7941.700000 104593.0100 13.1701
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Total 8938.950000 156201.5100 17.4743
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Number of Children (Unduplicated) With at Least One Service 803
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Center 04
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
25 243.000000 6075.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25 243.000000 6075.0000 0.0000
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
10 7.500000 428.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10 7.500000 428.6000 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 441 211.500000 7905.2500 0.0000
---------------------------------------------------------
Total 441 211.500000 7905.2500 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 21 22.500000 832.5000 0.0000
P 406 6960.500000 54819.5100 54819.5100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 347 514.500000 29093.5000 0.0000
T 0 0.000000 0.0000 0.0000
13 15.000000 772.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 787 7512.500000 85517.5100 54819.5100
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
15 16.000000 650.0800 81.4400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15 16.000000 650.0800 81.4400
Center 53
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
1 1.000000 50.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 50.0000 0.0000
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 430 439.750000 28597.2600 28597.2600
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
417 405.250000 23872.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 847 845.000000 52469.4100 28597.2600
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
3 11.750000 326.7500 225.0000
Other 49 90.700000 2778.9100 2678.9100
---------------------------------------------------------
Total 52 102.450000 3105.6600 2903.9100