CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 13207 41486.00000 1542599.9500 37.1836
Subtotal (Total Children Is Unduplicated) 13207 41486.00000 1542599.9500 37.1836
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 15.8400 15.8400
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 44 79.500000 5962.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 40 72.000000 5362.5000 74.4792
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 16.500000 1237.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 23 39.000000 2925.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 13 24.000000 1800.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 17 29.000000 2175.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 19.000000 1425.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 15.000000 1125.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 56 99.500000 5522.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 68 124.000000 6882.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 745 1318.250000 98800.5000 74.9482
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 770 1414.000000 105784.5000 74.8122
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 142 250.000000 18750.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 422 771.500000 57862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 210 395.000000 29625.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 311 543.000000 40725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 940 1678.000000 93073.5000 55.4669
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1096 2004.500000 111249.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 284 458.000000 34150.0000 74.5633
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 158 297.500000 22312.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 9 10.000000 514.1000 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 21 21.000000 1079.6100 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 10.000000 514.1000 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 16 17.000000 873.9700 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 205.6400 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 8 8.000000 411.2800 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 7.000000 359.8700 51.4100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SCREEN-T1023-SCREENING 39 39.000000 1950.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 40 42.000000 2159.2200 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 1 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 14.000000 719.7400 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 12.000000 616.9200 51.4100
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 4 4.000000 205.6400 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 4.000000 211.7200 52.9300
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 7 20.000000 1055.5600 52.7780
Subtotal (Total Children Is Unduplicated) 2989 9875.250000 658292.8700 66.6609
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5120 38072.00000 1902980.2400 49.9837
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1246 5661.750000 283016.0000 49.9874
OCCT-97530-OT SESSION BY LICENSED OT 413 2074.810000 148891.0600 71.7613
OCCT-97530GT-OT SESSION BY LICENSED OT 50 166.880000 11986.2300 71.8254
OCCT-97530HM-OT SESSION BY OT ASST 169 1046.500000 60278.3800 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 5 6.000000 323.9800 53.9967
OCCT-97530TL-OT SESSION BY LICENSED OT 116 501.000000 35890.0500 71.6368
OCCT-97530TLGT-OT SESSION BY LICENSED OT 39 108.750000 7825.6500 71.9600
OCCT-97530TLGTHM-OT SESSION BY OT ASST 2 1.500000 86.4000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 9 24.000000 1382.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 385 1796.750000 129269.4500 71.9463
PHY-97110GT-PT SESSION BY LICENSED PT 16 42.000000 3021.9600 71.9514
PHY-97110HM-PT SESSION BY PT ASST 69 452.500000 25958.1000 57.3660
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 8 17.250000 992.9100 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 142 638.000000 45874.5000 71.9036
PHY-97110TLGT-PT SESSION BY LICENSED PT 26 38.000000 2734.4800 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 5 23.000000 1323.8800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 563 3678.000000 264377.1200 71.8807
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 62 221.750000 15833.3100 71.4016
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 9.500000 547.2000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 2 9.000000 518.4000 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 150 688.250000 49448.8700 71.8473
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 55 143.500000 10326.2600 71.9600
Subtotal (Total Children Is Unduplicated) 7059 55420.69000 3002886.8300 54.1835
-----------------------------------------------------------------------------------------------------------------------
Total 106781.940000 5203779.6500 48.7328
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 14711
-----------------------------------------------------------------------------------------------------------------------
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 7 7.000000 350.0000 350.0000
D 65 66.000000 3525.6800 0.0000
S 0 0.000000 0.0000 0.0000
H 256 64.000000 2380.8000 2380.8000
T 3 2.750000 137.5000 137.5000
0 0.000000 0.0000 0.0000
Other 1 0.250000 9.3000 0.0000
---------------------------------------------------------
Total 332 140.000000 6403.2800 2868.3000
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 1742 1226.750000 52937.9500 0.0000
---------------------------------------------------------
Total 1742 1226.750000 52937.9500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 217 133.750000 5157.2000 0.0000
P 158 128.250000 5333.1500 5333.9900
D 1 0.500000 18.6000 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
1829 1410.750000 55005.6000 0.0000
Other 43 47.250000 1858.3500 0.0000
---------------------------------------------------------
Total 2252 1723.500000 67484.5000 5333.9900
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 210 326.500000 12902.5500 0.0000
U 0 0.000000 0.0000 0.0000
B 2014 3254.750000 126793.8000 0.0000
P 769 1270.750000 50602.4000 50212.8000
D 213 339.500000 12946.4900 0.0000
S 3 4.250000 158.1000 0.0000
H 2275 8797.500000 442183.7600 0.0000
T 0 0.000000 0.0000 0.0000
416 565.250000 33587.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5900 14558.500000 679174.2700 50212.8000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 38 22.250000 827.7000 0.0000
U 0 0.000000 0.0000 0.0000
B 3018 1916.250000 71284.5000 34977.2400
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
1 0.500000 18.6000 0.0000
Other 36 26.750000 995.1000 0.0000
---------------------------------------------------------
Total 3093 1965.750000 73125.9000 34977.2400
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
11123 10206.500000 489514.4300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11123 10206.500000 489514.4300 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 64 51.000000 2348.4000 0.0000
U 0 0.000000 0.0000 0.0000
B 1192 983.000000 45013.8000 0.0000
P 1907 1563.750000 66459.5000 66403.7000
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
5 4.250000 233.7000 0.0000
Other 125 78.250000 3437.7000 0.0000
---------------------------------------------------------
Total 3293 2680.250000 117493.1000 66403.7000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 196 195.750000 7548.9400 0.0000
U 0 0.000000 0.0000 0.0000
B 4271 4552.000000 186160.9300 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
1772 5979.500000 325029.0200 0.0000
Other 166 321.500000 22228.1000 0.0000
---------------------------------------------------------
Total 6405 11048.750000 540966.9900 0.0000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 82 67.750000 2520.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 9656 8692.250000 367300.8000 0.0000
P 3 3.250000 231.2600 1.0000
D 136 198.250000 13283.3600 0.0000
S 2 6.500000 357.9400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4985 14805.500000 837559.3700 0.0000
Other 431 306.250000 11392.5000 0.0000
---------------------------------------------------------
Total 15295 24079.750000 1232645.5300 1.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.000000 55.5000 0.0000
P 1 4.000000 200.0000 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
370 1216.500000 73506.7100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 372 1221.500000 73762.2100 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 13.000000 685.6200 0.0000
U 0 0.000000 0.0000 0.0000
B 998 1065.750000 56726.2700 74.4000
P 1361 1435.500000 66436.3500 66436.4200
D 8 12.000000 761.0000 0.0000
S 162 161.750000 6855.6000 563.9000
H 4 4.000000 287.8400 0.0000
T 1 1.000000 71.9600 0.0000
677 1429.750000 81458.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3224 4122.750000 213282.7400 67074.7200
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 115 114.500000 7888.4100 0.0000
U 0 0.000000 0.0000 0.0000
B 1313 1196.000000 58778.4900 0.0000
P 2320 2133.500000 104613.6700 104538.2100
D 15 13.500000 725.9800 0.0000
S 101 98.000000 4933.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1496 1557.750000 82888.4000 0.0000
Other 174 139.500000 7014.5800 59.2500
---------------------------------------------------------
Total 5534 5252.750000 266842.8300 104597.4600
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 8.750000 325.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2430 2318.250000 110078.3500 0.0000
P 3246 2968.000000 135780.6400 135771.3400
D 13 12.250000 710.5800 0.0000
S 17 17.000000 863.8400 0.0000
H 6 6.000000 431.7600 0.0000
T 0 0.000000 0.0000 0.0000
2285 2427.250000 128535.9000 0.0000
Other 136 108.440000 5299.9400 542.2400
---------------------------------------------------------
Total 8142 7865.940000 382026.5100 136313.5800
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2736 2867.000000 126736.5900 0.0000
P 1439 1450.250000 61638.5000 60837.9500
D 1 0.250000 9.3000 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
3625 3769.250000 229576.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7801 8086.750000 417960.5300 60837.9500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 33.500000 1246.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 2790 4054.750000 170991.6000 139.5000
P 1088 1589.250000 71019.1500 71019.3300
D 1 1.250000 46.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 15 24.500000 1593.7500 522.9000
1831 6749.250000 339681.6800 339681.6800
Other 134 150.000000 5580.0000 0.0000
---------------------------------------------------------
Total 5878 12602.500000 590158.8800 411363.4100