CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 173 272.000000 10137.0000 37.2684
Subtotal (Total Children Is Unduplicated) 173 272.000000 10137.0000 37.2684
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 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 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 39.000000 2925.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 33 41.000000 3075.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 111 165.500000 9185.2500 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 37 38.000000 2893.7000 76.1500
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 3.000000 150.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 48.000000 2400.0000 50.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 3 9.000000 462.6900 51.4100
Subtotal (Total Children Is Unduplicated) 183 406.500000 25397.3900 62.4782
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 18.500000 925.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 6 8.500000 425.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 28 29.500000 737.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 4 5.000000 250.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 5 5.000000 250.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 5.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 5.000000 125.0000 25.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 2 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 241 1265.000000 63100.0000 49.8814
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 11 27.000000 1350.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 262 1388.000000 6870.0000 4.9496
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 128 474.000000 5719.3500 12.0661
OCCT-97530-OT SESSION BY LICENSED OT 27 89.000000 6404.4400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 4.000000 287.8400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 18 73.000000 5149.4200 70.5400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 64 250.000000 17990.0000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 13.000000 935.4800 71.9600
TRAV-TRAVS-Travel by mile 562 33573.00000 14884.3300 0.4433
Subtotal (Total Children Is Unduplicated) 705 37243.25000 125903.3600 3.3806
-----------------------------------------------------------------------------------------------------------------------
Total 37921.750000 161437.7500 4.2571
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 971
-----------------------------------------------------------------------------------------------------------------------
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
93 123.000000 7611.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 93 123.000000 7611.2000 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
640 12674.000000 6680.4700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 640 12674.000000 6680.4700 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 85 85.000000 1156.0000 1156.0000
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 177 80.750000 3003.9000 0.0000
---------------------------------------------------------
Total 262 165.750000 4159.9000 1156.0000
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 1639 21657.250000 103902.3500 103902.3500
D 12 125.000000 549.8600 0.0000
S 0 0.000000 0.0000 0.0000
H 196 274.500000 15419.2500 0.0000
T 0 0.000000 0.0000 0.0000
236 2676.250000 18036.6000 0.0000
Other 3 5.000000 375.0000 0.0000
---------------------------------------------------------
Total 2086 24738.000000 138283.0600 103902.3500
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
30 143.500000 1002.6800 346.4300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 30 143.500000 1002.6800 346.4300
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
6 6.000000 110.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 6.000000 110.0000 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
61 68.500000 3374.5600 0.0000
Other 3 3.000000 215.8800 0.0000
---------------------------------------------------------
Total 64 71.500000 3590.4400 0.0000