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
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 1.500000 55.8000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 319 450.250000 16729.5000 37.1560
Subtotal (Total Children Is Unduplicated) 320 451.750000 16785.3000 37.1562
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.500000 75.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 84 130.000000 9750.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 63 94.000000 7050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 14 26.500000 1987.5000 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 143 218.500000 12126.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
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 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 200 603.500000 38481.1800 63.7633
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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 281 1518.000000 74214.7300 48.8898
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 119 666.500000 47961.3400 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) 1261 52326.67913 197739.7000 3.7789
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Total 53381.929129 253006.1800 4.7395
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Number of Children (Unduplicated) With at Least One Service 1603
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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
2241 21758.750000 10024.2800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2241 21758.750000 10024.2800 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 225 104.750000 3892.4500 0.0000
---------------------------------------------------------
Total 225 104.750000 3892.4500 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 1117 23613.000000 114706.4500 114706.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 369 530.500000 29705.8500 0.0000
T 517 6796.250000 66340.6000 66340.6000
69 77.500000 2883.0000 0.0000
Other 1 4.000000 200.0000 0.0000
---------------------------------------------------------
Total 2073 31021.250000 213835.9000 181047.0500
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
5 6.000000 310.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 6.000000 310.0000 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
150 138.500000 6661.0600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 206 193.500000 10296.6300 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
81 167.750000 10217.7500 2989.2500
Other 48 110.429129 3663.7100 3663.7100
---------------------------------------------------------
Total 135 294.179129 14423.4200 7194.9200