CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 16412 51202.50000 1893514.5000 36.9809
Subtotal (Total Children Is Unduplicated) 16412 51202.50000 1893514.5000 36.9809
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 14 14.000000 275.9400 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 16.000000 221.9200 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 14 14.000000 127.1200 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 16.000000 445.2800 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 50.1000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.000000 134.4000 22.4000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 105 161.500000 12112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 55 77.500000 5812.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 34 58.000000 4350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 73 119.500000 8962.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 138 223.000000 12376.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1378 2214.500000 165857.4000 74.8961
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 12 17.500000 1312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 706 1096.000000 82162.5000 74.9658
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 24 35.500000 2662.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 430 691.000000 51825.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1864 2880.500000 159812.2500 55.4807
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 35 62.000000 3385.5000 54.6048
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 710 1117.000000 83737.5000 74.9664
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 18.000000 1350.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 10.000000 510.5000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 87 88.000000 4492.4000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 19 19.000000 969.9500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 21 22.000000 1123.1000 51.0500
SCREEN-T1023-SCREENING 86 195.000000 9850.0000 50.5128
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 153.1500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 51 52.000000 2654.6000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 14 14.000000 714.7000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 6 6.000000 293.6400 48.9400
Subtotal (Total Children Is Unduplicated) 3121 9285.500000 619965.0000 66.7670
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 25 56.750000 1418.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6379 46155.50000 2307507.5000 49.9942
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 875 1312.000000 65600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 655 3111.750000 222200.8500 71.4070
OCCT-97530GT-OT SESSION BY LICENSED OT 71 94.750000 6758.2600 71.3273
OCCT-97530HM-OT SESSION BY OT ASST 267 1358.250000 77634.7000 57.1579
OCCT-97530HMGT-OT SESSION BY OT ASST 10 12.750000 729.3000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 3 3.000000 214.3200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 5 5.000000 357.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 634 3012.750000 215014.8100 71.3683
PHY-97110GT-PT SESSION BY LICENSED PT 54 72.250000 5161.5400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 101 618.250000 35339.1700 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 6 7.000000 500.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 956 5210.910134 371975.9200 71.3841
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 97 131.000000 9286.8000 70.8916
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 13 29.500000 1687.4000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 5 21.000000 1500.2400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 8.250000 589.3800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 7 13.000000 180.4400 13.8800
Subtotal (Total Children Is Unduplicated) 7915 61233.66013 3323656.6600 54.2783
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Total 121721.660134 5837136.1600 47.9548
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Number of Children (Unduplicated) With at Least One Service 17565
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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 2 1.750000 64.7500 64.7500
D 162 166.750000 9100.6000 0.0000
S 2 1.500000 89.9400 0.0000
H 11019 7526.750000 315686.1400 315265.2400
T 0 0.000000 0.0000 0.0000
1 1.500000 112.5000 0.0000
Other 230 361.000000 23116.5000 0.0000
---------------------------------------------------------
Total 11416 8059.250000 348170.4300 315329.9900
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 1774 1156.500000 50358.5000 0.0000
---------------------------------------------------------
Total 1774 1156.500000 50358.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 238 135.500000 5041.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3202 2278.250000 95633.5000 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
68 71.500000 4813.2800 0.0000
Other 46 26.000000 962.0000 0.0000
---------------------------------------------------------
Total 3554 2511.250000 106450.0300 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 37 50.750000 1877.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1268 1802.000000 70009.5000 101.7500
P 2759 4278.000000 166826.6700 164337.3100
D 1 1.000000 75.0000 0.0000
S 2 4.000000 148.0000 0.0000
H 2810 9739.500000 496606.5700 0.0000
T 0 0.000000 0.0000 0.0000
665 819.250000 36287.5000 0.0000
Other 4 6.000000 222.0000 0.0000
---------------------------------------------------------
Total 7546 16700.500000 772052.9900 164439.0600
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 14.750000 685.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3197 2112.000000 81565.4500 55809.8700
P 1 2.000000 100.0000 100.0000
D 1 1.000000 37.0000 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 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3220 2129.750000 82388.2000 55909.8700
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
11479 9722.500000 467020.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11479 9722.500000 467020.1400 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 21 123.750000 6008.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 975 725.750000 28430.2500 0.0000
P 3367 2835.000000 119859.2500 120553.7000
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
55 38.750000 1447.8000 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 4419 3723.500000 155755.3000 120553.7000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 181 176.750000 6927.7500 0.0000
P 4204 4423.250000 178742.2500 178742.2500
D 52 47.500000 1757.5000 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
2698 7926.000000 442630.5200 0.0000
Other 173 294.500000 21639.0000 0.0000
---------------------------------------------------------
Total 7309 12870.000000 651847.0200 178742.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 139 107.500000 4459.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1083 814.250000 32301.7500 9.2500
P 8925 7133.000000 297929.8600 307688.8500
D 20 20.250000 969.9700 0.0000
S 14 35.000000 1750.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5212 13660.250000 755091.3900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15393 21770.250000 1092502.2200 307698.1000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1114 828.750000 34664.8300 0.0000
P 381 307.500000 12088.5000 11939.7500
D 14 12.500000 538.0000 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
711 2000.750000 120284.4900 0.0000
Other 1 1.000000 71.4400 0.0000
---------------------------------------------------------
Total 2221 3150.500000 167647.2600 11939.7500
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 5 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 324 303.750000 15124.9100 150.0000
P 1382 1396.750000 65254.1600 65080.6200
D 0 0.000000 0.0000 0.0000
S 483 468.250000 17888.2500 233.2500
H 35 42.000000 2818.6800 447.7600
T 1 3.000000 214.3200 0.0000
1112 2171.750000 132917.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3342 4388.750000 234338.1000 65911.6300
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 4.250000 170.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 982 872.750000 38963.1500 1335.4400
P 3311 2911.750000 134050.3000 135772.2200
D 221 204.000000 13524.4200 71.4400
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1557 1620.500000 85072.1000 150.0000
Other 21 25.000000 1657.2800 0.0000
---------------------------------------------------------
Total 6098 5638.250000 273437.5000 137329.1000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1417 1200.750000 56538.5500 157.2500
P 5343 4234.000000 185384.9700 191275.7500
D 213 186.000000 11400.3400 3.3000
S 0 0.000000 0.0000 0.0000
H 4 3.250000 126.7500 34.2500
T 0 0.000000 0.0000 0.0000
3443 3529.250000 180309.8300 0.0000
Other 67 64.500000 3960.0200 0.0000
---------------------------------------------------------
Total 10487 9217.750000 437720.4600 191470.5500
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1181 974.000000 40243.5300 129.5000
P 3646 2777.500000 112010.9900 128246.2900
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
5124 5290.160134 312750.2100 0.0000
Other 3 3.000000 193.9300 0.0000
---------------------------------------------------------
Total 9954 9044.660134 465198.6600 128375.7900
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 355 366.000000 15413.5000 18.5000
P 4464 4628.000000 182377.0000 180150.6720
D 13 6.500000 240.5000 0.0000
S 1 3.000000 111.0000 111.0000
H 4 4.750000 213.7500 75.0000
T 0 0.000000 0.0000 0.0000
2194 6630.000000 333893.6000 333943.6000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7031 11638.250000 532249.3500 514298.7720