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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 219 340.500000 12685.2000 37.2546
Subtotal (Total Children Is Unduplicated) 219 340.500000 12685.2000 37.2546
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
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 4 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 23.500000 1762.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 41 66.000000 4950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 44 54.000000 4050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 28.000000 2100.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 26.000000 1443.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 149 216.500000 12015.7500 55.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 40 41.000000 3122.1500 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) 243 547.000000 34558.0900 63.1775
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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
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Total 38130.750000 173146.6500 4.5409
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Number of Children (Unduplicated) With at Least One Service 1036
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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
108 143.500000 8805.4000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 108 143.500000 8805.4000 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 192 91.500000 3403.8000 0.0000
---------------------------------------------------------
Total 277 176.500000 4559.8000 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 1645 21667.750000 104650.8500 104650.8500
D 12 125.000000 549.8600 0.0000
S 0 0.000000 0.0000 0.0000
H 319 439.000000 24683.2500 0.0000
T 0 0.000000 0.0000 0.0000
237 2677.250000 18073.8000 0.0000
Other 3 5.000000 375.0000 0.0000
---------------------------------------------------------
Total 2216 24914.000000 148332.7600 104650.8500
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
62 70.250000 3439.6600 0.0000
Other 3 3.000000 215.8800 0.0000
---------------------------------------------------------
Total 65 73.250000 3655.5400 0.0000