CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 237 335.250000 12471.3000 37.2000
Subtotal (Total Children Is Unduplicated) 237 335.250000 12471.3000 37.2000
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Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 0.500000 25.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 42 60.500000 4537.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 68 101.500000 7612.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 126 114.000000 6327.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 85 116.000000 6438.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 62 62.000000 4721.3000 76.1500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
OCTF-97168-OT RE-EVAL EST PLAN CARE 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 12 69.000000 3651.2000 52.9159
Subtotal (Total Children Is Unduplicated) 298 559.000000 35629.5400 63.7380
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 29 46.000000 2300.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 2 2.000000 100.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 25 30.000000 750.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 5.000000 250.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 6 6.000000 300.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 6 3.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 23 268.000000 6700.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 323 1726.000000 86300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 18.000000 900.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 238 842.000000 8798.1200 10.4491
OCCT-97530-OT SESSION BY LICENSED OT 77 305.761534 21940.6400 71.7574
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 2 8.000000 460.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 62 216.000000 15543.3600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 3 13.000000 935.4800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 2 7.750000 446.0900 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 139 609.000000 43823.6400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 4.000000 287.8400 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.569966 32.8300 57.5999
TRAV-TRAVS-Travel by mile 1055 58114.00000 25744.5200 0.4430
Subtotal (Total Children Is Unduplicated) 1342 62240.08150 216410.2800 3.4770
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Total 63134.331500 264511.1200 4.1897
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Number of Children (Unduplicated) With at Least One Service 1754
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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
212 382.000000 16324.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 212 382.000000 16324.0200 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
3118 29506.250000 15057.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3118 29506.250000 15057.9400 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 87 111.000000 1769.6500 1769.6500
D 1 0.500000 18.6000 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 0.500000 18.6000 0.0000
Other 228 107.750000 4083.9000 0.0000
---------------------------------------------------------
Total 317 219.750000 5890.7500 1769.6500
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 661 10028.750000 88350.3900 88350.3900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 258 340.500000 19102.2000 0.0000
T 1230 22368.000000 108752.3800 108752.3800
90 117.250000 4421.9200 0.0000
Other 3 6.000000 450.0000 0.0000
---------------------------------------------------------
Total 2242 32860.500000 221076.8900 197102.7700
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 1 2.000000 100.0000 0.0000
5 6.000000 331.9600 115.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 8.000000 431.9600 115.2000
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 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
4 2.500000 143.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4 2.500000 143.9000 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
25 122.500000 4600.0000 3913.0000
Other 21 32.831500 985.6600 985.6600
---------------------------------------------------------
Total 46 155.331500 5585.6600 4898.6600