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
Agency Filter:EIP DEI DEIP
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
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 0.500000 25.0000 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 33 42.500000 3187.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 51 70.000000 5250.0000 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 83 112.000000 6216.0000 55.5000
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
Subtotal (Total Children Is Unduplicated) 253 423.500000 27166.0200 64.1464
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 6 3.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 4.000000 200.0000 50.0000
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 4.000000 287.8400 71.9600
Subtotal (Total Children Is Unduplicated) 9 12.000000 537.8400 44.8200
-----------------------------------------------------------------------------------------------------------------------
Total 770.750000 40175.1600 52.1248
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 413
-----------------------------------------------------------------------------------------------------------------------
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
194 181.000000 11299.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 194 181.000000 11299.0200 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 0 0.000000 0.0000 0.0000
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 230 108.750000 4121.1000 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 3 2.250000 143.9200 143.9200
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 9 6.500000 200.0000 200.0000
90 117.250000 4421.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 360 466.500000 23868.0400 343.9200
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
2 3.000000 200.0000 115.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 3.000000 200.0000 115.2000
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
7 11.500000 687.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7 11.500000 687.0000 0.0000