CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 Page: 1
List order: No List
Payclass Filters:MED
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 13916 41169.25000 1522669.7500 36.9856
Subtotal (Total Children Is Unduplicated) 13916 41169.25000 1522669.7500 36.9856
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 45.000000 3336.0000 74.1333
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 63 110.000000 8133.0000 73.9364
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 39 67.500000 5062.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 16.500000 1237.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 15 26.000000 1950.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 31.000000 2325.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 24 38.500000 2887.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 35 59.000000 3274.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 61 104.500000 5799.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 243 451.500000 33862.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 986 1750.500000 131219.2500 74.9610
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 103 190.500000 14177.0000 74.4199
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 521 869.000000 65125.0000 74.9425
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 97 187.500000 14062.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 329 601.500000 45037.5000 74.8753
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 348 656.500000 36354.5000 55.3762
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1253 2176.000000 120731.0000 55.4830
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 154 288.500000 21637.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 365 618.500000 46387.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 24 24.000000 1413.8400 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 23.4200 23.4200
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 8 8.250000 421.1625 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 3.500000 178.6750 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 33 33.000000 1684.6500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTF-97164TL-PT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161TL-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.500000 433.9250 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 16 16.000000 800.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 16.000000 816.8000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 22 22.000000 1123.1000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 6 6.500000 331.8250 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.1000 44.5500
Subtotal (Total Children Is Unduplicated) 2534 8492.750000 573368.6375 67.5127
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 6 13.500000 337.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3730 23800.00000 1189480.0000 49.9782
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1679 7860.750000 392987.5000 49.9936
OCCT-97530-OT SESSION BY LICENSED OT 379 1519.000000 108374.4800 71.3459
OCCT-97530GT-OT SESSION BY LICENSED OT 69 210.750000 15055.9800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 163 739.750000 42313.7000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 8 28.000000 1601.6000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 63 228.250000 16306.1800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 119 385.250000 27522.2600 71.4400
OCCT-97530TLHM-OT SESSION BY OT ASST 45 235.250000 13456.3000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 413 1655.200448 118018.9600 71.3019
PHY-97110GT-PT SESSION BY LICENSED PT 90 270.500000 19324.5200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 67 330.500000 18891.3800 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 3.000000 171.4800 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 77 234.000000 16716.9600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 80 316.000000 22575.0400 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 13 68.000000 3886.8800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 543 2718.500000 193979.4000 71.3553
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 115 460.750000 32915.9800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 199 860.750000 61491.9800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 140 546.750000 39002.2600 71.3347
SPL-92508-GROUP SPL SESSION PER CHILD 5 22.250000 308.8300 13.8800
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 Page: 2
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Subtotal (Total Children Is Unduplicated) 6565 42506.70045 2334719.1700 54.9259
-----------------------------------------------------------------------------------------------------------------------
Total 92168.700448 4430757.5575 48.0723
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 15333
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 0.500000 18.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 99 108.000000 5819.4400 0.0000
S 4455 2704.250000 118875.7800 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
11 5.250000 194.2500 0.0000
Other 158 213.750000 13082.5000 0.0000
---------------------------------------------------------
Total 4726 3032.250000 138008.9700 0.0000
Center 02
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
0 0.000000 0.0000 0.0000
Other 1178 922.750000 41682.2500 0.0000
---------------------------------------------------------
Total 1178 922.750000 41682.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 158 122.250000 4746.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2608 1919.000000 91256.1000 18.5000
P 110 99.250000 5086.7000 5086.7000
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
29 26.750000 1894.9400 0.0000
Other 13 8.250000 311.7500 0.0000
---------------------------------------------------------
Total 2918 2175.500000 103295.9900 5105.2000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 164 290.250000 11975.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 404 597.000000 28425.0000 0.0000
P 625 1055.500000 45319.5500 44215.5400
D 24 37.250000 1955.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1755 6543.500000 331295.7200 0.0000
T 0 0.000000 0.0000 0.0000
2228 3782.750000 145596.2600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5200 12306.250000 564567.0300 44215.5400
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 242 162.750000 6021.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2661 1814.500000 69049.2700 36810.5700
P 0 0.000000 0.0000 0.0000
D 2 0.500000 18.5000 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 3.750000 138.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2910 1981.500000 75228.2700 36810.5700
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
11044 9376.000000 437826.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11044 9376.000000 437826.0100 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 312 221.000000 8177.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 649 534.000000 23563.7500 0.0000
P 2833 2368.500000 101452.0000 101479.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.500000 18.5000 0.0000
T 0 0.000000 0.0000 0.0000
16 10.250000 455.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3811 3134.250000 133666.5000 101479.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 285 283.500000 10593.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 913 924.250000 35993.7500 0.0000
P 2857 3119.000000 124461.7500 124380.2700
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 1 2.000000 150.0000 300.0000
1395 4630.250000 260721.6200 0.0000
Other 155 307.500000 21619.5000 0.0000
---------------------------------------------------------
Total 5606 9266.500000 453539.8700 124680.2700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 291 253.500000 9727.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 7834 6622.250000 277472.7500 0.0000
P 20 31.500000 1783.9400 780.9400
D 113 81.500000 3224.5000 0.0000
S 110 210.000000 14432.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3224 10408.250000 588120.0275 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11592 17607.000000 894760.9675 780.9400
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 67 70.000000 4372.5000 0.0000
P 1 1.000000 55.5000 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
729 1792.750000 107021.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 797 1863.750000 111449.6800 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 217 249.500000 14033.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 1391 1322.500000 57648.7600 111.0000
P 1273 1214.000000 52760.5300 52154.9900
D 0 0.000000 0.0000 0.0000
S 267 236.250000 9971.0100 0.0000
H 0 0.000000 0.0000 0.0000
T 2 0.500000 18.5000 18.5000
652 1239.000000 75030.9800 0.0000
Other 1 2.500000 92.5000 0.0000
---------------------------------------------------------
Total 3803 4264.250000 209556.1800 52284.4900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2317 2083.500000 100236.3400 0.0000
U 0 0.000000 0.0000 0.0000
B 1562 1324.750000 64236.9300 0.0000
P 1093 993.500000 46791.0400 46791.0400
D 32 34.500000 2123.1800 0.0000
S 157 164.000000 10682.2600 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 74.0000 0.0000
1073 1113.750000 58516.1000 0.0000
Other 14 14.750000 811.1700 0.0000
---------------------------------------------------------
Total 6249 5730.750000 283471.0200 46791.0400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 63 47.500000 2559.6400 0.0000
U 0 0.000000 0.0000 0.0000
B 1590 1317.750000 58537.8400 87.0000
P 1687 1453.000000 65553.3400 72251.7900
D 9 11.250000 804.5700 0.0000
S 14 16.750000 1214.7100 0.0000
H 1 0.250000 9.2500 9.2500
T 0 0.000000 0.0000 0.0000
4264 3993.250000 191294.7900 0.0000
Other 21 16.500000 1106.9000 69.2500
---------------------------------------------------------
Total 7649 6856.250000 321081.0400 72417.2900
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3800 3060.500000 126855.6200 0.0000
P 9 8.250000 305.2500 305.2500
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
3205 3287.700448 197748.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7014 6356.450448 324909.4000 305.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 446 618.250000 23017.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 578 749.250000 31452.0000 46.2500
P 1318 1616.250000 67493.2500 67020.0000
D 7 14.250000 527.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.500000 187.5000 0.0000
T 1 1.250000 46.2500 46.2500
1199 4293.500000 214990.8800 214036.6300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3551 7295.250000 337714.3800 281149.1300