CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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 12964 39062.75000 1444817.7500 36.9871
Subtotal (Total Children Is Unduplicated) 12964 39062.75000 1444817.7500 36.9871
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 27.500000 2062.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 45 76.500000 5670.7500 74.1275
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 23 35.500000 2625.0000 73.9437
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 11 18.500000 1387.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 20 34.500000 2558.2500 74.1522
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 34 61.000000 3385.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 65 105.000000 5827.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 300 557.000000 41725.0000 74.9102
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1002 1760.000000 131912.2500 74.9501
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 120 223.500000 16762.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 383 652.000000 48862.5000 74.9425
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 114 213.000000 15975.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 277 508.500000 38137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 415 773.000000 42901.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1248 2150.000000 119297.2500 55.4871
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 183 330.000000 24750.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 336 566.000000 42450.0000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 5 5.000000 151.7500 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 471.2800 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 23.4200 23.4200
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 8.000000 408.4000 51.0500
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 18 25.000000 1276.2500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 29 42.000000 2144.1000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTF-97164TL-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 10 10.000000 510.5000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TLGT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
PSTH-97163TLGT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 24 24.000000 1200.0000 50.0000
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 29 29.000000 1480.4500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 18 19.000000 969.9500 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 6.000000 306.3000 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 2595 8351.000000 560000.8500 67.0579
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 2.750000 68.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3857 23098.00000 1154774.0000 49.9945
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1500 6670.250000 333499.5000 49.9981
OCCT-97530-OT SESSION BY LICENSED OT 413 1607.250000 114821.9400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 63 215.750000 15413.1800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 154 680.500000 38867.4000 57.1159
OCCT-97530HMGT-OT SESSION BY OT ASST 7 18.500000 1058.2000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 84 273.000000 19485.2600 71.3746
OCCT-97530TLGT-OT SESSION BY LICENSED OT 115 332.500000 23753.8000 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 3 9.000000 514.8000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 47 208.500000 11926.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 408 1565.250000 111800.0200 71.4263
PHY-97110GT-PT SESSION BY LICENSED PT 88 306.500000 21878.5000 71.3817
PHY-97110HM-PT SESSION BY PT ASST 84 472.250000 26993.8100 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.500000 85.7400 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 74 223.000000 15931.1200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 79 241.500000 17252.7600 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 12 76.250000 4358.4500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 562 2744.000000 195532.2400 71.2581
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 105 374.000000 26718.5600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 27 177.750000 10167.3000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 233 1070.750000 76494.3800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 165 602.250000 42852.5000 71.1540
SPL-92508-GROUP SPL SESSION PER CHILD 10 25.250000 350.4700 13.8800
Subtotal (Total Children Is Unduplicated) 6568 40996.25000 2264598.8800 55.2392
-----------------------------------------------------------------------------------------------------------------------
Total 88410.000000 4269417.4800 48.2911
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 14602
-----------------------------------------------------------------------------------------------------------------------
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 0 0.000000 0.0000 0.0000
D 84 85.500000 4487.2100 0.0000
S 1021 920.500000 56448.2400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 0.250000 9.2500 0.0000
Other 167 274.250000 17351.5000 0.0000
---------------------------------------------------------
Total 1273 1280.500000 78296.2000 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 1329 961.250000 41341.2500 0.0000
---------------------------------------------------------
Total 1329 961.250000 41341.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2547 2092.500000 100760.4700 0.0000
P 1 1.000000 71.4400 71.4400
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
39 35.500000 2487.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2590 2129.750000 103347.5400 71.4400
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2127 3400.500000 132790.0000 0.0000
P 845 1485.250000 58455.0000 57891.4700
D 7 10.000000 370.0000 0.0000
S 2 3.750000 138.7500 0.0000
H 1610 5896.250000 297873.6200 0.0000
T 0 0.000000 0.0000 0.0000
357 507.250000 24581.7000 0.0000
Other 2 5.000000 255.2500 51.0500
---------------------------------------------------------
Total 4950 11308.000000 514464.3200 57942.5200
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2643 1800.750000 68077.4600 33295.5700
P 0 0.000000 0.0000 0.0000
D 4 3.500000 232.8200 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 2.000000 74.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2653 1806.250000 68384.2800 33295.5700
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
10501 8846.500000 414106.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10501 8846.500000 414106.0200 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 63 45.000000 1665.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 850 679.750000 28881.7500 0.0000
P 2637 2335.500000 100378.7500 100149.3500
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 0 0.000000 0.0000 0.0000
11 6.000000 222.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3561 3066.250000 131147.5000 100149.3500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.250000 46.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 748 764.250000 29974.6300 0.0000
P 3333 3482.500000 138386.1200 138336.1200
D 2 3.250000 120.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4 2.000000 74.0000 98.0500
1626 5151.250000 287343.5600 0.0000
Other 127 250.500000 17676.0000 412.5000
---------------------------------------------------------
Total 5841 9655.000000 473620.8100 138846.6700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 12.000000 444.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 8791 7896.500000 334130.7500 0.0000
P 7 17.500000 1211.4600 206.2000
D 180 165.750000 7922.0000 0.0000
S 2 7.500000 385.7200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2847 8951.500000 511097.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11840 17050.750000 855191.6000 206.2000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 19 22.000000 1445.2500 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
874 1842.000000 109088.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 893 1864.000000 110533.4400 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 608 658.500000 32451.0300 0.0000
P 2224 2192.750000 95522.4000 94812.6600
D 1 2.000000 150.0000 0.0000
S 136 121.500000 5447.9000 131.0500
H 4 5.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
710 1392.000000 86103.3300 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 3685 4372.500000 220002.4100 94943.7100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 31.000000 1550.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2275 2031.250000 97916.9400 74.0000
P 1655 1458.750000 69454.4100 69097.2100
D 65 65.000000 4468.4200 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
1102 1120.250000 57536.1400 0.0000
Other 66 60.500000 3332.4100 0.0000
---------------------------------------------------------
Total 5194 4766.750000 234258.3200 69171.2100
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2824 2409.500000 106940.2600 0.0000
P 2447 2031.500000 89889.8900 89818.4520
D 14 13.500000 713.9400 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 71.4400 0.0000
T 0 0.000000 0.0000 0.0000
1874 1955.500000 104005.3600 0.0000
Other 64 55.500000 3065.5200 0.0000
---------------------------------------------------------
Total 7224 6466.500000 304686.4100 89818.4520
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3706 2867.000000 117935.7900 0.0000
P 2 0.500000 18.5000 18.5000
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
2917 3002.000000 182521.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6625 5869.500000 300475.4100 18.5000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 11.000000 407.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2887 3755.500000 151364.7500 0.0000
P 215 262.250000 11266.2500 11099.7500
D 0 0.000000 0.0000 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1366 4937.250000 256505.4700 256274.2200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4473 8966.500000 419561.9700 267373.9700