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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 13726 42504.75000 1572171.7500 36.9881
Subtotal (Total Children Is Unduplicated) 13726 42504.75000 1572171.7500 36.9881
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 35.000000 2625.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 57 98.500000 7320.7500 74.3223
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 25 39.000000 2887.5000 74.0385
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 19 33.000000 2475.0000 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 22 37.500000 2783.2500 74.2200
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 42 76.500000 4245.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 84 142.000000 7881.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 359 652.500000 48887.5000 74.9234
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1320 2286.500000 171380.2500 74.9531
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 147 263.500000 19762.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 507 849.000000 63637.5000 74.9558
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 134 247.500000 18562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 365 656.000000 49200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 491 897.000000 49783.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1620 2748.500000 152514.0000 55.4899
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 214 383.000000 28725.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 425 724.000000 54300.0000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 5 5.000000 151.7500 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 589.1000 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 25 26.000000 1300.0000 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) 3261 10432.50000 700899.1700 67.1842
-----------------------------------------------------------------------------------------------------------------------
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 3858 23105.00000 1155124.0000 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:Program Patients
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) 6569 41003.25000 2264948.8800 55.2383
-----------------------------------------------------------------------------------------------------------------------
Total 93940.500000 4538019.8000 48.3074
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 15455
-----------------------------------------------------------------------------------------------------------------------
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 1104 1032.000000 64032.2400 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 218 350.250000 22174.0000 0.0000
---------------------------------------------------------
Total 1407 1468.000000 90702.7000 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 1398 1023.250000 44169.0000 0.0000
---------------------------------------------------------
Total 1398 1023.250000 44169.0000 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 2711 2293.250000 110816.9700 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
40 37.500000 2598.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2755 2332.500000 113515.0400 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 2218 3549.250000 139445.2500 0.0000
P 900 1568.000000 62282.0000 61718.8000
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
384 541.000000 26580.5200 0.0000
Other 2 5.000000 255.2500 51.0500
---------------------------------------------------------
Total 5123 11573.250000 526945.3900 61769.8500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2843 1995.750000 75292.4600 37263.8200
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 2853 2001.250000 75599.2800 37263.8200
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
11073 9502.000000 446459.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11073 9502.000000 446459.0200 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 68 49.500000 1831.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 886 736.750000 31401.7500 0.0000
P 2801 2526.750000 109109.0000 108849.6000
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 3766 3319.000000 142564.2500 108849.6000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.250000 46.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 777 811.750000 32125.6300 0.0000
P 3556 3827.500000 153878.3700 153819.1200
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
1645 5186.750000 290006.0600 0.0000
Other 188 367.000000 25848.0000 412.5000
---------------------------------------------------------
Total 6173 10199.500000 502098.5600 154329.6700
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 12.000000 444.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 9146 8368.750000 356136.5000 0.0000
P 9 21.500000 1511.4600 281.2000
D 186 177.000000 8612.0000 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
2849 8958.500000 511447.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12205 17545.250000 878537.3500 281.2000
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
888 1857.000000 109991.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 907 1879.000000 111436.6900 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 630 695.000000 34442.5300 0.0000
P 2335 2364.000000 103509.4000 102800.1100
D 1 2.000000 150.0000 0.0000
S 140 126.750000 5718.1500 131.0500
H 4 5.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
715 1400.750000 86655.0800 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 3827 4594.250000 230802.9100 102931.1600
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 31.000000 1550.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2434 2211.250000 106224.9400 74.0000
P 1775 1598.250000 76549.4100 76192.2100
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
1126 1159.250000 59767.6400 0.0000
Other 66 60.500000 3332.4100 0.0000
---------------------------------------------------------
Total 5497 5125.250000 251892.8200 76266.2100
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3043 2667.000000 118460.7600 0.0000
P 2594 2222.000000 98642.3900 98570.9520
D 15 15.500000 863.9400 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
1925 2038.250000 108932.1100 0.0000
Other 65 57.500000 3139.5200 0.0000
---------------------------------------------------------
Total 7643 7001.250000 330110.1600 98570.9520
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4249 3552.000000 150145.7900 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
3000 3168.000000 193528.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7251 6720.500000 343692.4100 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 3263 4398.000000 179097.2500 0.0000
P 247 309.500000 13466.0000 13299.5000
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 4881 9656.250000 449494.2200 269573.7200