CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/10/2023 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 11963 34914.25000 1298413.0500 37.1886
Subtotal (Total Children Is Unduplicated) 11963 34914.25000 1298413.0500 37.1886
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Screening, Eval, and Assessment,Class #02
AACIS-92597-AAC INTIAL EVAL BY LICENSED SLP 3 3.000000 310.0800 103.3600
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 47 88.500000 6637.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 31 56.500000 4237.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 23.000000 1725.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 19 34.000000 2550.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 19.500000 1462.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 12 21.500000 1612.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 35.500000 2662.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 43 79.000000 4384.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 43 76.000000 4218.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 636 1170.500000 87787.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 717 1270.000000 95230.0000 74.9843
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 219 388.000000 29100.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 378 670.000000 50250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 171 310.000000 23362.5000 75.3629
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 215 381.000000 28537.5000 74.9016
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 746 1319.000000 73160.2500 55.4665
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 985 1755.500000 97469.2500 55.5222
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 227 348.500000 26287.5000 75.4304
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 227 388.500000 29137.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 21 21.000000 1079.6100 51.4100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 6 6.000000 308.4600 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 11 11.000000 565.5100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 22 22.000000 1131.0200 51.4100
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 4.000000 205.6400 51.4100
PSTH-97163TLGT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 18 18.000000 862.5000 47.9167
SPCH-92521-EVAL OF SPEECH FLUENCY 25 25.000000 1285.2500 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 13.000000 668.3300 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 308.4600 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 264.6500 52.9300
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 6 17.000000 873.9700 51.4100
Subtotal (Total Children Is Unduplicated) 2704 8613.500000 579374.4500 67.2635
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EI Services,Class #03
AACFIT-92609-AAC FITTING, ADJUST, TRAINING VISIT 5 5.000000 212.0500 42.4100
AACFIT-92609TL-AAC FITTING, ADJUST, TRAINING VISIT 1 3.000000 127.2300 42.4100
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 7 28.000000 700.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4560 25540.00000 1276624.0000 49.9853
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 977 3545.250000 177312.5000 50.0141
OCCT-97530-OT SESSION BY LICENSED OT 378 1531.500000 110148.4600 71.9219
OCCT-97530GT-OT SESSION BY LICENSED OT 43 86.500000 6224.5400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 153 831.500000 47973.3600 57.6950
OCCT-97530HMGT-OT SESSION BY OT ASST 5 7.000000 403.1600 57.5943
OCCT-97530TL-OT SESSION BY LICENSED OT 130 431.000000 31014.7600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 51 110.000000 7915.6000 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 5 9.000000 518.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 356 1280.000000 92048.8400 71.9132
PHY-97110GT-PT SESSION BY LICENSED PT 17 26.000000 1863.7600 71.6831
PHY-97110HM-PT SESSION BY PT ASST 84 378.000000 21754.1000 57.5505
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 12 31.250000 1798.7700 57.5606
PHY-97110TL-PT SESSION BY LICENSED PT 139 653.000000 46989.8800 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 31 41.500000 2986.3400 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 7 34.750000 2043.4100 58.8032
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 486 2383.000000 171174.8500 71.8317
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 62 147.500000 10614.1000 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 31.000000 1785.6000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 2 4.500000 259.2000 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 142 439.250000 31608.4300 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 47 83.750000 6026.6500 71.9600
Subtotal (Total Children Is Unduplicated) 6357 37661.25000 2050127.9900 54.4360
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Total 81189.000000 3927915.4900 48.3799
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Number of Children (Unduplicated) With at Least One Service 13841
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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 3 3.000000 150.0000 150.0000
D 37 38.500000 2160.8900 0.0000
S 24 26.000000 1852.1900 0.0000
H 672 690.000000 43100.2700 43100.2700
T 0 0.000000 0.0000 0.0000
15 8.500000 316.2000 316.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 751 766.000000 47579.5500 43566.4700
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 1709 1194.250000 50956.8700 0.0000
---------------------------------------------------------
Total 1709 1194.250000 50956.8700 0.0000
Center 03
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
1893 1356.000000 53284.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1893 1356.000000 53284.6500 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 4.000000 148.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 2072 3383.000000 135534.1000 0.0000
P 298 521.500000 20638.8600 19823.5000
D 111 162.750000 6081.7500 0.0000
S 2 3.750000 139.5000 0.0000
H 1497 5808.500000 292047.2100 0.0000
T 0 0.000000 0.0000 0.0000
532 759.500000 39320.8200 0.0000
Other 1 0.750000 27.9000 0.0000
---------------------------------------------------------
Total 4515 10643.750000 493938.9400 19823.5000
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 84 68.750000 2557.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2701 1722.250000 64067.7000 46211.7000
P 0 0.000000 0.0000 0.0000
D 16 9.250000 344.1000 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
3 1.000000 37.2000 0.0000
Other 53 34.500000 1283.4000 0.0000
---------------------------------------------------------
Total 2857 1835.750000 68289.9000 46211.7000
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
9560 8481.750000 397640.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9561 8482.250000 397659.2800 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 19.500000 725.4000 0.0000
U 0 0.000000 0.0000 0.0000
B 855 780.500000 38084.2000 0.0000
P 1792 1486.000000 64411.7500 64411.7500
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
6 7.500000 354.6000 0.0000
Other 110 68.250000 2838.9000 0.0000
---------------------------------------------------------
Total 2794 2361.750000 106414.8500 64411.7500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 103 98.500000 3819.6800 0.0000
U 0 0.000000 0.0000 0.0000
B 3199 3471.250000 144134.3300 0.0000
P 148 155.500000 8153.1000 8189.7000
D 52 53.000000 2624.4000 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
3363 3434.500000 187285.0700 0.0000
Other 187 353.500000 24419.5500 0.0000
---------------------------------------------------------
Total 7052 7566.250000 370436.1300 8189.7000
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 322 274.750000 10586.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 7841 7064.250000 309000.0000 0.0000
P 14 24.250000 1508.5500 133.0000
D 91 77.000000 3354.6500 0.0000
S 4 6.500000 445.7800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4376 9675.250000 542417.3000 0.0000
Other 461 355.500000 13495.5000 0.0000
---------------------------------------------------------
Total 13109 17477.500000 880808.0300 133.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 29 29.500000 1637.2500 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
376 1157.250000 72127.7600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 405 1186.750000 73765.0100 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 34 34.000000 1986.1200 0.0000
U 0 0.000000 0.0000 0.0000
B 862 853.500000 40705.0600 50.0000
P 1350 1343.250000 65233.3800 65183.5800
D 11 11.750000 739.5000 0.0000
S 162 156.000000 6482.5000 297.2000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
901 915.750000 51823.1100 0.0000
Other 1 0.250000 9.3000 9.3000
---------------------------------------------------------
Total 3321 3314.500000 166978.9700 65540.0800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 80 64.750000 3757.9500 0.0000
U 0 0.000000 0.0000 0.0000
B 736 671.250000 34949.1800 0.0000
P 2229 2055.500000 100648.0900 100632.5300
D 4 3.000000 146.3600 0.0000
S 32 33.250000 2333.3200 0.0000
H 3 3.000000 215.8800 0.0000
T 0 0.000000 0.0000 0.0000
879 914.750000 49793.2100 0.0000
Other 222 193.000000 10339.7200 0.0000
---------------------------------------------------------
Total 4185 3938.500000 202183.7100 100632.5300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 72 76.750000 4589.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 1007 1018.000000 47980.9000 109.1600
P 3386 3170.000000 146215.4900 146014.0400
D 0 0.000000 0.0000 0.0000
S 9 7.000000 381.1200 0.0000
H 11 10.500000 463.1600 0.0000
T 0 0.000000 0.0000 0.0000
1016 1084.750000 56823.4300 0.0000
Other 158 133.750000 7002.2900 90.0000
---------------------------------------------------------
Total 5659 5500.750000 263455.9900 146213.2000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1907 1951.750000 84546.6500 0.0000
P 1220 1241.000000 50218.6000 49293.5500
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
2792 2970.000000 180850.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5919 6162.750000 315615.3700 49293.5500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 189 271.000000 10081.2000 0.0000
U 0 0.000000 0.0000 0.0000
B 2976 4258.000000 183306.1500 0.0000
P 61 62.000000 3111.0000 3111.0000
D 0 0.000000 0.0000 0.0000
S 11 11.000000 550.0000 550.0000
H 0 0.000000 0.0000 0.0000
T 4 4.000000 200.0000 165.0000
4616 4604.750000 232188.2900 231712.8300
Other 183 191.500000 7111.6000 25.0000
---------------------------------------------------------
Total 8040 9402.250000 436548.2400 235563.8300