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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 282 394.750000 14684.7000 37.2000
Subtotal (Total Children Is Unduplicated) 282 394.750000 14684.7000 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 12 14.500000 1087.5000 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 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 14 17.000000 943.5000 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 61 86.000000 6450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 86 129.000000 9675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 151 136.500000 7575.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 112 148.500000 8241.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.000000 675.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 72 72.000000 5482.8000 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) 377 709.000000 45623.5400 64.3491
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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 1056 58158.00000 25764.1000 0.4430
Subtotal (Total Children Is Unduplicated) 1343 62284.08150 216429.8600 3.4749
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Total 63387.831500 276738.1000 4.3658
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Number of Children (Unduplicated) With at Least One Service 1845
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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
247 414.500000 18334.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 247 414.500000 18334.2700 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
3124 29550.250000 15077.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3124 29550.250000 15077.5200 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 237 111.750000 4232.7000 0.0000
---------------------------------------------------------
Total 326 223.750000 6039.5500 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 662 10030.750000 88500.3900 88500.3900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 360 462.500000 25951.0500 0.0000
T 1246 22399.000000 111048.1300 111048.1300
98 132.250000 4979.9200 0.0000
Other 3 6.000000 450.0000 0.0000
---------------------------------------------------------
Total 2369 33030.500000 230929.4900 199548.5200
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
27 125.500000 4795.7500 3913.0000
Other 21 32.831500 985.6600 985.6600
---------------------------------------------------------
Total 48 158.331500 5781.4100 4898.6600