CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 14035 44006.00000 1636650.0000 37.1915
Subtotal (Total Children Is Unduplicated) 14035 44006.00000 1636650.0000 37.1915
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 37 69.000000 5175.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 41 74.500000 5587.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 14.000000 1050.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 20 36.000000 2700.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 22.500000 1687.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 18 35.000000 2625.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 30.500000 2287.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 15 24.000000 1800.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 39 65.500000 3635.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 76 138.000000 7659.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 636 1146.773600 85913.5200 74.9176
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 860 1529.000000 114616.5000 74.9617
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 199 326.500000 24487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 494 878.500000 65887.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 187 349.500000 26212.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 313 548.500000 41137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 906 1582.000000 87773.2500 55.4825
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1340 2395.000000 132922.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 379 625.000000 46837.5000 74.9400
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 306 596.500000 44737.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 380.7500 76.1500
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.2300 142.2300
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 10.000000 514.1000 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 16 17.000000 873.9700 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 6 6.000000 308.4600 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 15 15.000000 771.1500 51.4100
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 19 24.000000 1233.8400 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 9.000000 462.6900 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 7 5.500000 282.7550 51.4100
PSTH-97161TL-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97163TLGT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 30 30.000000 1500.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 32 31.250000 1606.5625 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92521TLGT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 14.000000 719.7400 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.4100 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 9 31.000000 1640.8300 52.9300
Subtotal (Total Children Is Unduplicated) 3268 10714.02360 716660.4875 66.8899
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 13.000000 325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4383 27818.25000 1390807.5000 49.9962
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1281 5226.500000 261083.0000 49.9537
OCCT-97530-OT SESSION BY LICENSED OT 388 1783.500000 128268.7000 71.9197
OCCT-97530GT-OT SESSION BY LICENSED OT 59 137.750000 9912.4900 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 155 883.500000 50889.5600 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 6 15.500000 892.8000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 126 460.750000 33155.5700 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 57 135.500000 9750.5800 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 10 57.000000 3283.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 368 1645.500000 118410.1800 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 22 58.250000 4137.6000 71.0318
PHY-97110HM-PT SESSION BY PT ASST 64 324.250000 18663.8300 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 5 14.750000 849.0100 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 139 590.750000 42510.3700 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 32 43.750000 3148.2500 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 9 45.750000 2633.3700 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 542 3095.500000 222379.4400 71.8396
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 84 277.250000 19924.2000 71.8637
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.750000 216.0000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 9.750000 561.6000 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 143 554.500000 39863.7800 71.8914
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 49 126.000000 8995.0000 71.3889
Subtotal (Total Children Is Unduplicated) 6427 43321.00000 2370661.0300 54.7231
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Total 98041.023600 4723971.5175 48.1836
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Number of Children (Unduplicated) With at Least One Service 15379
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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 59 59.500000 3038.1700 0.0000
S 3993 2943.250000 134643.0200 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 50.0000 50.0000
0 0.000000 0.0000 0.0000
Other 234 331.000000 21653.4000 0.0000
---------------------------------------------------------
Total 4287 3334.750000 159384.5900 50.0000
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 1828 1435.250000 62894.6500 0.0000
---------------------------------------------------------
Total 1828 1435.250000 62894.6500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 49 63.500000 2362.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 1969 1331.000000 50937.6500 0.0000
P 175 104.750000 4182.0500 4111.3500
D 18 13.500000 710.1000 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
8 11.000000 464.1000 0.0000
Other 184 168.750000 6473.7000 0.0000
---------------------------------------------------------
Total 2403 1692.500000 65129.8000 4111.3500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2331 3444.500000 135460.6500 0.0000
P 623 1002.750000 40960.1500 40400.7000
D 114 133.000000 5114.1000 0.0000
S 0 0.000000 0.0000 0.0000
H 1394 5176.500000 260812.1800 0.0000
T 0 0.000000 0.0000 0.0000
602 747.750000 38478.3500 0.0000
Other 1 1.500000 55.8000 0.0000
---------------------------------------------------------
Total 5065 10506.000000 480881.2300 40400.7000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3378 2070.750000 77031.9000 14756.4500
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
10 6.750000 251.1000 0.0000
Other 89 65.250000 2427.3000 0.0000
---------------------------------------------------------
Total 3477 2142.750000 79710.3000 14756.4500
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.6000 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
10744 9577.750000 451078.6100 0.0000
Other 1 1.000000 37.2000 0.0000
---------------------------------------------------------
Total 10746 9579.250000 451134.4100 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 6.000000 223.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 944 852.000000 39189.6000 0.0000
P 1804 1555.750000 67578.9000 67439.4000
D 0 0.000000 0.0000 0.0000
S 1 0.500000 18.6000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
30 18.500000 688.2000 0.0000
Other 184 111.500000 4385.0000 0.0000
---------------------------------------------------------
Total 2970 2544.250000 112083.5000 67439.4000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3507 3795.250000 150734.1500 211.0000
P 1049 1099.250000 46852.8500 46770.8100
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
1416 4931.000000 271526.9300 0.0000
Other 210 401.750000 28631.2500 0.0000
---------------------------------------------------------
Total 6182 10227.250000 497745.1800 46981.8100
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 6.750000 251.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 10149 8829.250000 370133.7000 0.0000
P 2 5.000000 359.8000 40.0000
D 183 220.500000 13131.8600 0.0000
S 3 7.000000 415.8800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3932 11418.750000 654127.0175 0.0000
Other 394 297.250000 11057.7000 0.0000
---------------------------------------------------------
Total 14671 20784.500000 1049477.0575 40.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 7 13.000000 750.7500 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
360 1083.500000 65886.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 367 1096.500000 66636.8800 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 20.000000 883.0400 0.0000
U 0 0.000000 0.0000 0.0000
B 875 908.250000 46050.9400 0.0000
P 1619 1696.000000 78576.5000 78577.1500
D 1 1.000000 50.0000 0.0000
S 158 133.000000 6263.1500 652.3000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
518 1059.750000 62173.3400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3190 3818.000000 193996.9700 79229.4500
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 5.250000 246.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 601 564.500000 29660.8800 0.0000
P 2538 2409.500000 120831.8700 120778.4900
D 43 43.000000 2459.3900 0.0000
S 160 120.500000 5461.9000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1328 1399.500000 72322.7300 0.0000
Other 220 181.250000 7880.2400 0.0000
---------------------------------------------------------
Total 4896 4723.500000 238863.5100 120778.4900
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 18.750000 842.6200 0.0000
U 0 0.000000 0.0000 0.0000
B 1083 1029.500000 50927.2200 109.1600
P 4842 4540.750000 208083.0300 207779.7200
D 52 62.750000 3899.3000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 5.000000 359.8000 0.0000
T 0 0.000000 0.0000 0.0000
1766 1925.500000 103003.0900 0.0000
Other 105 88.000000 4110.8000 889.7200
---------------------------------------------------------
Total 7869 7670.250000 371225.8600 208778.6000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2729 2819.750000 125792.6500 0.0000
P 1059 1074.750000 45926.7000 45926.7000
D 0 0.000000 0.0000 0.0000
S 2 3.273600 245.5200 0.0000
H 1 0.500000 18.6000 0.0000
T 0 0.000000 0.0000 0.0000
3114 3223.750000 193036.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6905 7122.023600 365020.0400 45926.7000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2569 3802.500000 160312.9500 334.3500
P 1195 1817.000000 82163.1300 81263.4800
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 9 17.500000 1205.2500 601.0500
1513 5506.500000 277894.3100 277894.3100
Other 192 220.750000 8211.9000 0.0000
---------------------------------------------------------
Total 5478 11364.250000 529787.5400 360093.1900