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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 14773 44764.50000 1655499.7500 36.9824
Subtotal (Total Children Is Unduplicated) 14773 44764.50000 1655499.7500 36.9824
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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 27 48.500000 3569.2500 73.5928
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 85 150.500000 11170.5000 74.2226
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 43 75.500000 5662.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 18.000000 1350.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 21 37.000000 2775.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 33.000000 2475.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 30 48.500000 3637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 40 68.000000 3774.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 80 136.500000 7575.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 277 506.500000 37987.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1330 2331.500000 174794.2500 74.9707
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 121 219.000000 16314.5000 74.4954
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 668 1106.500000 82937.5000 74.9548
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 111 213.500000 16012.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 466 825.000000 61800.0000 74.9091
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 398 745.000000 41266.2500 55.3909
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1645 2817.500000 156334.2500 55.4869
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 174 329.000000 24675.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 475 787.000000 59025.0000 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 17 17.000000 850.0000 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) 3218 10701.75000 723954.8875 67.6483
-----------------------------------------------------------------------------------------------------------------------
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 3731 23807.00000 1189830.0000 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 116 463.250000 33094.5800 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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Subtotal (Total Children Is Unduplicated) 6567 42516.20045 2335247.7700 54.9261
-----------------------------------------------------------------------------------------------------------------------
Total 97982.450448 4714702.4075 48.1178
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 16219
-----------------------------------------------------------------------------------------------------------------------
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 4728 2935.500000 129537.7800 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.500000 18.5000 0.0000
13 8.250000 390.0000 0.0000
Other 202 265.250000 16291.0000 0.0000
---------------------------------------------------------
Total 5045 3318.000000 152075.2200 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 1303 1055.000000 48263.5000 0.0000
---------------------------------------------------------
Total 1303 1055.000000 48263.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 165 133.000000 5257.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2695 2028.500000 97117.3500 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 3012 2295.750000 109667.9900 5105.2000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 181 308.250000 13093.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 433 632.750000 30350.7500 0.0000
P 669 1120.250000 48129.3000 47025.2900
D 25 38.250000 2030.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1757 6550.500000 331645.7200 0.0000
T 0 0.000000 0.0000 0.0000
2326 3958.750000 152759.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5391 12608.750000 578008.7800 47025.2900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 254 177.000000 6549.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2844 1998.250000 76095.0200 40932.3200
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 3105 2179.500000 82801.2700 40932.3200
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
11485 9877.500000 462820.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11485 9877.500000 462820.0100 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 320 235.750000 8722.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 680 578.250000 25729.0000 0.0000
P 2964 2545.000000 110100.5000 110128.2500
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
19 13.250000 642.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3984 3372.750000 145213.0000 110128.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 298 306.500000 11481.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 983 1039.500000 40716.7500 0.0000
P 3050 3446.000000 139336.0000 139273.0200
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
1415 4669.750000 263684.1200 0.0000
Other 248 484.000000 34155.0000 0.0000
---------------------------------------------------------
Total 5995 9947.750000 489523.1200 139573.0200
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 296 261.750000 10069.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 8180 7043.750000 297180.5000 0.0000
P 23 37.500000 2194.9400 883.6900
D 114 82.000000 3243.0000 0.0000
S 150 281.500000 19424.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3226 10410.750000 588298.6275 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11989 18117.250000 920411.0675 883.6900
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 90 93.000000 5844.0000 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
737 1799.750000 107356.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 828 1893.750000 113256.1800 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 222 259.500000 14744.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 1457 1411.250000 61432.2600 111.0000
P 1327 1289.250000 55950.5300 55344.9900
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
662 1257.750000 76135.7300 0.0000
Other 1 2.500000 92.5000 0.0000
---------------------------------------------------------
Total 3938 4457.000000 218345.4300 55474.4900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2467 2237.000000 107346.8400 0.0000
U 0 0.000000 0.0000 0.0000
B 1756 1520.750000 73390.1800 0.0000
P 1203 1120.750000 53041.5400 53041.5400
D 32 34.500000 2123.1800 0.0000
S 164 174.000000 11432.2600 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 74.0000 0.0000
1096 1152.250000 60974.6000 0.0000
Other 14 14.750000 811.1700 0.0000
---------------------------------------------------------
Total 6733 6256.000000 309193.7700 53041.5400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 63 47.500000 2559.6400 0.0000
U 0 0.000000 0.0000 0.0000
B 1720 1453.750000 64650.8400 87.0000
P 1828 1644.750000 74581.0900 81418.6900
D 9 11.250000 804.5700 0.0000
S 19 24.250000 1777.2100 0.0000
H 1 0.250000 9.2500 9.2500
T 0 0.000000 0.0000 0.0000
4514 4311.000000 206946.2900 0.0000
Other 24 22.500000 1461.9000 214.2500
---------------------------------------------------------
Total 8178 7515.250000 352790.7900 81729.1900
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4389 3788.500000 161194.6200 0.0000
P 10 9.250000 342.2500 342.2500
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
3292 3461.700448 209511.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7691 7259.450448 371048.4000 342.2500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 509 726.500000 27323.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 666 888.250000 37982.2500 46.2500
P 1493 1896.750000 80013.5000 79431.7500
D 9 15.750000 582.7500 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
1201 4297.750000 215148.1300 214036.6300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3881 7828.750000 361283.8800 293560.8800