CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 1 1.500000 75.0000 50.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.3300 142.3300
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 78.000000 3900.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 32 107.000000 5753.5200 53.7712
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 20 34.500000 1725.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 17 19.500000 487.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 278 1512.000000 73914.7300 48.8854
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 8.000000 400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 28 85.000000 792.6700 9.3255
OCCT-97530-OT SESSION BY LICENSED OT 48 237.429129 17085.4000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 18.000000 1036.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 59 386.000000 27674.6700 71.6960
PHY-97110GT-PT SESSION BY LICENSED PT 7 40.000000 2878.4000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 172.6800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 115 651.500000 46881.9400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 9.750000 701.6100 71.9600
TRAV-TRAVS-Travel by mile 1034 49284.00000 21758.9000 0.4415
Subtotal (Total Children Is Unduplicated) 1254 52305.67913 196360.3000 3.7541
-----------------------------------------------------------------------------------------------------------------------
Total 52412.679129 202113.8200 3.8562
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1270
-----------------------------------------------------------------------------------------------------------------------
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
2241 21758.750000 10024.2800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2241 21758.750000 10024.2800 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 1114 23608.000000 114331.4500 114331.4500
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 516 6795.000000 66294.1000 66294.1000
0 0.000000 0.0000 0.0000
Other 1 4.000000 200.0000 0.0000
---------------------------------------------------------
Total 1631 30407.000000 180825.5500 180625.5500
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
3 4.000000 210.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 4.000000 210.0000 0.0000
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
2 3.500000 223.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 3.500000 223.5000 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 56 55.000000 3635.5700 3635.5700
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 56 55.000000 3635.5700 3635.5700
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 6 16.000000 541.9600 541.9600
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
22 58.000000 2989.2500 2989.2500
Other 48 110.429129 3663.7100 3663.7100
---------------------------------------------------------
Total 76 184.429129 7194.9200 7194.9200