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
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 3 2.250000 83.5500 37.1333
TCM-T1017TL-TARGETED CASE MANAGEMENT 1195 1732.250000 64409.8500 37.1828
Subtotal (Total Children Is Unduplicated) 1197 1734.500000 64493.4000 37.1827
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 5 4.500000 225.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 0.500000 25.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 14 27.500000 1375.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 26 34.000000 2550.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 16 23.000000 1725.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 7.000000 388.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 40 52.000000 2886.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 61.000000 4555.5000 74.6803
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 253 365.000000 27375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 257 374.000000 28050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 20.000000 1500.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 40 70.500000 5287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 333 287.000000 15928.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 546 695.500000 38600.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 24.000000 1800.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 167 167.000000 12704.2400 76.0733
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.3300 142.3300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 94.4100 31.4700
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 6 6.000000 307.7400 51.2900
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 12 74.000000 3915.8500 52.9169
Subtotal (Total Children Is Unduplicated) 1251 2512.206575 160753.5800 63.9890
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 91 134.500000 6725.0000 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
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 9 4.750000 0.0000 0.0000
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 725 7189.250000 355154.1500 49.4007
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 26 79.000000 3950.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 50.0000 25.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 373 1307.000000 14070.2400 10.7653
OCCT-97530-OT SESSION BY LICENSED OT 179 1346.749308 96257.8100 71.4742
OCCT-97530GT-OT SESSION BY LICENSED OT 3 6.000000 430.2000 71.7000
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 383 3207.755838 230418.5300 71.8317
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 24 81.000000 5816.2800 71.8059
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 11.168057 643.2800 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 20.0000 20.0000
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 2
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
TRAV-TRAVS-Travel by mile 2541 257798.0000 114165.1300 0.4428
Subtotal (Total Children Is Unduplicated) 3162 273948.4874 978854.3700 3.5731
-----------------------------------------------------------------------------------------------------------------------
Total 278195.194016 1204101.3500 4.3283
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 4852
-----------------------------------------------------------------------------------------------------------------------
Center 01
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 1 2.000000 50.0000 50.0000
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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 2.000000 50.0000 50.0000
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
686 1214.000000 50417.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 686 1214.000000 50417.1500 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
12006 113464.750000 54639.3900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12006 113464.750000 54639.3900 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 178 242.250000 3941.1500 3941.1500
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
2 0.750000 27.9000 0.0000
Other 1324 647.500000 24348.8000 0.0000
---------------------------------------------------------
Total 1505 891.000000 28336.4500 3941.1500
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 7055 136044.000000 743891.1800 743891.1800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1427 1944.000000 108846.0000 0.0000
T 1252 22407.500000 111615.5500 111615.5500
195 254.750000 9536.9200 0.0000
Other 4 10.000000 650.0000 0.0000
---------------------------------------------------------
Total 9933 160660.250000 974539.6500 855506.7300
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 30 36.000000 2100.0000 1390.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 7 13.000000 688.6400 588.6400
38 60.250000 1861.3600 702.5400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 75 109.250000 4650.0000 2681.1800
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 682 703.500000 46311.2400 46311.2400
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
375 334.000000 16713.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1057 1037.500000 63024.8500 46311.2400
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
97 346.000000 15663.7100 14480.9600
Other 264 443.776689 11968.9000 11968.9000
---------------------------------------------------------
Total 379 808.444016 27945.3600 26762.6100