CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 1 3.750000 139.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 224 340.500000 12666.6000 37.2000
Subtotal (Total Children Is Unduplicated) 224 344.250000 12806.1000 37.2000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 3 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 3 6.000000 300.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 10.500000 787.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 15 19.000000 1054.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 63 79.500000 5962.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 56 73.500000 5512.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 19 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 142 109.500000 6077.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 183 205.000000 11377.5000 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 57 57.000000 4340.5500 76.1500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 11 34.000000 1700.0000 50.0000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 264.6500 52.9300
Subtotal (Total Children Is Unduplicated) 411 654.000000 41155.5600 62.9290
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 10 13.500000 675.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 2 3.000000 150.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 15 14.750000 368.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 1.000000 50.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.500000 12.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 1.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 29.000000 1450.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 279 1370.000000 68058.2300 49.6775
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 8.000000 400.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 50.0000 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 19 42.000000 410.0000 9.7619
OCCT-97530-OT SESSION BY LICENSED OT 57 275.000000 19789.0000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 172.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 48 326.000000 23458.9600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 7.000000 503.7200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 123 537.500000 38606.5400 71.8261
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 33.000000 2374.6800 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 20.0000 20.0000
TRAV-TRAVS-Travel by mile 927 46116.00000 20474.5000 0.4440
Subtotal (Total Children Is Unduplicated) 1108 48789.50000 177306.1000 3.6341
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Total 49787.750000 231267.7600 4.6451
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Number of Children (Unduplicated) With at Least One Service 1591
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Center 01
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 50.0000 50.0000
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 50.0000 50.0000
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
272 222.750000 13500.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 272 222.750000 13500.0700 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
2152 20779.500000 9696.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2152 20779.500000 9696.0200 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 3 3.250000 66.5000 66.5000
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 125 55.500000 2064.6000 0.0000
---------------------------------------------------------
Total 128 58.750000 2131.1000 66.5000
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 1036 19624.500000 118631.2100 118631.2100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 396 511.500000 28592.8500 0.0000
T 0 0.000000 0.0000 0.0000
493 8446.000000 53506.2300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1925 28582.000000 200730.2900 118631.2100
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 10 10.000000 500.0000 350.0000
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 30.250000 367.8400 195.3400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25 40.250000 867.8400 545.3400
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 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
20 65.500000 3721.0300 3497.5300
Other 15 36.000000 521.4100 521.4100
---------------------------------------------------------
Total 35 101.500000 4242.4400 4018.9400