CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 13 25.500000 1275.0000 50.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 34.000000 2550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 29 54.000000 4050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 25 46.000000 3450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 15.000000 1125.0000 75.0000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.3300 142.3300
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 13.000000 650.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 23 147.000000 7350.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 3 2.595604 133.0800 51.2713
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 3.610971 184.5600 51.1109
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.4600 51.2300
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.6100 51.1220
SPCH-92521-EVAL OF SPEECH FLUENCY 15 15.000000 768.6300 51.2420
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.2800 51.3200
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 12 74.000000 3915.8500 52.9169
Subtotal (Total Children Is Unduplicated) 180 492.206575 29585.1700 60.1072
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 90 133.250000 6662.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 9 11.500000 575.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 118 133.500000 3337.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 10 10.000000 500.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 4 5.000000 250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 2.000000 50.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 16.000000 800.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 6 6.000000 300.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 2.000000 50.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 11 11.000000 550.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 13 13.000000 650.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 5 5.500000 275.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 50 766.000000 19150.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 16 57.000000 2850.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 713 7145.250000 352954.1500 49.3970
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 75.000000 3750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 367 1300.000000 14010.2400 10.7771
OCCT-97530-OT SESSION BY LICENSED OT 179 1346.749308 96257.8100 71.4742
OCCT-97530GT-OT SESSION BY LICENSED OT 2 4.000000 286.2800 71.5700
OCCT-97530HM-OT SESSION BY OT ASST 22 146.564238 8416.0000 57.4219
PHY-97110-PT SESSION BY LICENSED PT 150 1437.000000 103139.5300 71.7742
PHY-97110GT-PT SESSION BY LICENSED PT 15 90.000000 6460.8000 71.7867
PHY-97110HM-PT SESSION BY PT ASST 10 62.750000 3594.2900 57.2795
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 379 3156.755838 226760.5300 71.8334
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 19 76.000000 5457.0000 71.8026
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 11.168057 643.2800 57.6000
TRAV-TRAVS-Travel by mile 2538 257657.0000 114105.4800 0.4429
Subtotal (Total Children Is Unduplicated) 3132 273685.4874 972041.0200 3.5517
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Total 274177.694016 1001626.1900 3.6532
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Number of Children (Unduplicated) With at Least One Service 3195
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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
66 669.000000 16725.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 66 669.000000 16725.0000 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
11990 113342.750000 54585.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11990 113342.750000 54585.0800 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 176 241.000000 3894.6500 3894.6500
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 176 241.000000 3894.6500 3894.6500
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 7029 136008.500000 741573.3500 741573.3500
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 1224 22364.500000 108746.3000 108746.3000
0 0.000000 0.0000 0.0000
Other 4 10.000000 650.0000 0.0000
---------------------------------------------------------
Total 8257 158383.000000 850969.6500 850319.6500
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 7 13.000000 688.6400 588.6400
17 21.000000 893.5200 282.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 24 34.000000 1582.1600 870.6400
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
5 8.000000 498.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 8.000000 498.5000 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 676 691.500000 45450.2400 45450.2400
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
23 21.500000 1188.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 699 713.000000 46638.5400 45450.2400
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 2 2.188160 157.4600 157.4600
D 0 0.000000 0.0000 0.0000
S 10 21.479167 632.8900 632.8900
H 0 0.000000 0.0000 0.0000
T 6 -5.000000 -477.6000 -477.6000
86 327.500000 14480.9600 14480.9600
Other 261 440.776689 11938.9000 11938.9000
---------------------------------------------------------
Total 365 786.944016 26732.6100 26732.6100