CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/11/2023 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 141 170.250000 6314.7000 37.0907
Subtotal (Total Children Is Unduplicated) 141 170.250000 6314.7000 37.0907
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Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 11.500000 638.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 39 62.500000 4650.0000 74.4000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 42 61.000000 4575.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 62.000000 3441.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 125 175.000000 9712.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 1979.9000 76.1500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 239 447.000000 28294.2600 63.2981
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 18 29.500000 1475.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 14 15.000000 375.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 6 6.000000 300.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 7 7.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 35 446.000000 11150.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 144 452.000000 22600.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 10 19.000000 950.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 5 12.000000 180.0000 15.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 15 40.000000 545.0000 13.6250
OCCT-97530-OT SESSION BY LICENSED OT 23 49.000000 3526.0400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 4.500000 323.8200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 2 2.000000 115.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 7 11.000000 791.5600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 5.500000 395.7800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 7 13.000000 748.2800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 53.000000 3813.8800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 8.000000 575.6800 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 7.500000 432.0000 57.6000
TRAV-TRAVS-Travel by mile 242 13876.00000 6154.7000 0.4436
Subtotal (Total Children Is Unduplicated) 494 15062.00000 54751.9400 3.6351
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Total 15679.250000 89360.9000 5.6993
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Number of Children (Unduplicated) With at Least One Service 808
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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
180 460.500000 16476.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 180 460.500000 16476.5000 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
714 12330.000000 7970.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 714 12330.000000 7970.6300 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 39 39.000000 566.0000 566.0000
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 152 75.750000 2817.9000 0.0000
---------------------------------------------------------
Total 191 114.750000 3383.9000 566.0000
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 702 2182.500000 31780.4100 31780.4100
D 4 4.000000 200.0000 200.0000
S 0 0.000000 0.0000 0.0000
H 192 281.000000 15691.2000 0.0000
T 8 8.000000 400.0000 400.0000
15 15.500000 838.5100 0.0000
Other 3 5.000000 375.0000 0.0000
---------------------------------------------------------
Total 924 2496.000000 49285.1200 32380.4100
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 6 6.000000 300.0000 300.0000
17 17.000000 867.9300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23 23.000000 1167.9300 300.0000
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
1 1.000000 50.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 50.0000 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 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 57.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 1.000000 57.6000 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
232 251.000000 10866.4000 4246.8800
Other 2 2.000000 102.8200 102.8200
---------------------------------------------------------
Total 234 253.000000 10969.2200 4349.7000