CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 ending 06/30/2020 Date of Report:07/21/2020 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 32092 203571.2500 7528660.0000 36.9829
Subtotal (Total Children Is Unduplicated) 32092 203571.2500 7528660.0000 36.9829
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 19 19.000000 375.8100 19.7795
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 20 20.000000 278.7900 13.9395
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 19 19.000000 174.0600 9.1611
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 19 19.000000 528.7700 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 66.8000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 9 9.000000 200.7200 22.3022
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 349 543.500000 40762.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 62 98.500000 7387.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 181 271.000000 20287.5000 74.8616
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 32 44.000000 3300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 97 160.500000 12037.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 22 37.000000 2775.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 262 438.500000 32850.0000 74.9145
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 37 62.000000 4625.0000 74.5968
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 462 723.500000 40154.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 86 134.500000 7464.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4728 7507.633333 562644.7400 74.9430
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 958 1648.170133 123429.0100 74.8885
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2301 3556.371733 266550.0000 74.9500
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 422 700.000000 52500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1588 2497.500000 187234.5000 74.9688
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 444 773.500000 57973.5000 74.9496
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6689 10329.00000 572977.5000 55.4727
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1267 2126.000000 117877.6500 55.4457
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2638 4245.946133 318295.9600 74.9647
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 481 897.500000 67312.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 353.4600 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 83.2900 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 46.8400 23.4200
OCTF-97168-OT RE-EVAL EST PLAN CARE 37 38.000000 1939.9000 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 12 12.000000 612.6000 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 47 48.000000 2450.4000 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-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 268 282.000000 14396.1000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 11 11.000000 561.5500 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 12 12.000000 612.6000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 43 48.000000 2450.4000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 137 149.000000 7606.4500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 258 390.000000 19700.0000 50.5128
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 204.2000 51.0500
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 197 224.000000 11435.2000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 7 7.000000 357.3500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 33 33.000000 1684.6500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 5 5.000000 255.2500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 23 25.000000 1223.5000 48.9400
SPCH-92610TLGT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUN 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 12432 38237.62133 2568890.3500 67.1823
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 59.000000 6295.9700 106.7114
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 48 170.750000 4268.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10480 161812.2100 8089931.3000 49.9958
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3479 21855.50000 1092735.0000 49.9982
OCCT-97530-OT SESSION BY LICENSED OT 1189 10347.67721 738872.3900 71.4047
OCCT-97530GT-OT SESSION BY LICENSED OT 229 985.000000 70357.7200 71.4292
OCCT-97530HM-OT SESSION BY OT ASST 530 4868.250000 278265.0600 57.1592
OCCT-97530HMGT-OT SESSION BY OT ASST 51 239.750000 13713.7000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 33 68.750000 4840.0600 70.4009
OCCT-97530TLGT-OT SESSION BY LICENSED OT 126 480.750000 34344.7800 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 9 29.000000 1658.8000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 3 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1089 10819.05020 771952.4100 71.3512
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2019 ending 06/30/2020 Date of Report:07/21/2020 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
PHY-97110GT-PT SESSION BY LICENSED PT 234 865.750000 61478.3600 71.0117
PHY-97110HM-PT SESSION BY PT ASST 236 2315.975682 132381.1700 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 11 29.250000 1671.9300 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 36 80.750000 5768.7800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 100 404.000000 28800.9200 71.2894
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1706 17926.82405 1278395.8900 71.3119
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 378 1548.000000 110517.2800 71.3936
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 49 224.250000 12827.1000 57.2000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 1.500000 85.8000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 75 236.500000 16895.5600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 159 570.000000 40720.8000 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 52 125.250000 1738.4700 13.8800
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 9 10.500000 145.7400 13.8800
Subtotal (Total Children Is Unduplicated) 13435 236078.2372 12798892.5400 54.2146
-----------------------------------------------------------------------------------------------------------------------
Total 477887.108482 22896442.8900 47.9118
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 32738
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.750000 27.7500 0.0000
P 8346 5692.500000 222522.2000 222438.4500
D 636 633.250000 32884.7000 0.0000
S 4389 2928.000000 120135.3500 0.0000
H 29260 20951.250000 911045.9300 910287.6700
T 0 0.000000 0.0000 0.0000
77 97.000000 5915.0000 0.0000
Other 951 1483.000000 95600.2500 129.5000
---------------------------------------------------------
Total 43660 31785.750000 1388131.1800 1132855.6200
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 7581 5035.750000 222505.5000 0.0000
---------------------------------------------------------
Total 7581 5035.750000 222505.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 200 161.500000 6650.9600 0.0000
U 0 0.000000 0.0000 0.0000
B 14459 10188.000000 422775.7800 0.0000
P 2 0.750000 27.7500 27.7500
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
216 234.750000 15539.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14877 10585.000000 444993.6400 27.7500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 503 635.250000 23504.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 5094 7364.000000 278608.0000 37.0000
P 12940 19305.500000 761688.0100 731164.1500
D 2 2.000000 112.0000 0.0000
S 3 6.000000 222.0000 0.0000
H 10511 38975.750000 1987404.5300 0.0000
T 0 0.000000 0.0000 0.0000
1078 1060.750000 68109.0300 0.0000
Other 6 12.000000 582.1000 200.0000
---------------------------------------------------------
Total 30137 67361.250000 3120229.9200 731401.1500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 30 34.750000 2168.0700 0.0000
U 0 0.000000 0.0000 0.0000
B 11884 7918.250000 304370.8400 254953.8000
P 1 2.000000 100.0000 100.0000
D 126 103.000000 4057.7100 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 3.250000 120.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12046 8061.250000 310816.8700 255053.8000
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 3 3.000000 111.0000 111.0000
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
45454 38390.750000 1838849.0400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 45457 38393.750000 1838960.0400 111.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 133 119.750000 5258.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2350 1786.250000 71363.7000 0.0000
P 13664 11756.250000 495685.2500 497509.4500
D 4 4.500000 166.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 74.0000 0.0000
T 0 0.000000 0.0000 0.0000
99 80.250000 3229.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16251 13749.000000 575777.5000 497509.4500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 42 53.000000 2239.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 814 876.000000 34171.7500 0.0000
P 17279 18648.000000 753598.7500 753598.7500
D 117 107.250000 3968.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4 18.500000 684.5000 573.5000
9576 29529.750000 1658159.3900 0.0000
Other 749 1318.000000 96032.2500 0.0000
---------------------------------------------------------
Total 28581 50550.500000 2548853.8900 754172.2500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 492 377.000000 14271.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4181 3156.750000 128442.5000 83.2500
P 36711 29090.000000 1214503.0200 1221022.8830
D 165 127.750000 5174.7200 0.0000
S 179 343.500000 22089.1900 0.0000
H 1 3.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
17401 51691.000000 2808419.4400 0.0000
Other 61 113.750000 8357.5000 0.0000
---------------------------------------------------------
Total 59191 84902.750000 4201407.3700 1221106.1330
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 8.000000 296.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4347 3211.500000 130383.0800 0.0000
P 2263 1712.250000 67757.2500 67583.0000
D 72 51.750000 2300.2100 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
3293 9370.000000 571393.6800 0.0000
Other 2 2.000000 126.9400 0.0000
---------------------------------------------------------
Total 9992 14355.500000 772257.1600 67583.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 6.000000 450.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1669 1684.750000 76023.3400 175.0000
P 6418 6341.500000 295322.8200 294806.4100
D 0 0.000000 0.0000 0.0000
S 856 914.500000 35403.8300 564.2000
H 59 65.000000 4441.7500 447.7600
T 2 4.000000 251.3200 0.0000
3753 7590.250000 460858.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12760 16606.000000 872751.9700 295993.3700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 39 30.500000 1548.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 3617 3156.750000 151650.4000 149.1900
P 12547 11551.710000 533301.5200 534595.8900
D 644 575.000000 34249.9300 0.0000
S 0 0.000000 0.0000 0.0000
H 43 42.500000 2827.1600 50.0000
T 0 0.000000 0.0000 0.0000
6994 7154.750000 371395.5400 0.0000
Other 215 209.250000 14304.8100 0.0000
---------------------------------------------------------
Total 24099 22720.460000 1109277.4500 534795.0800
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 18 15.500000 1047.0500 0.0000
U 0 0.000000 0.0000 0.0000
B 3469 2882.000000 134544.1100 157.2500
P 20339 16741.000000 746518.1000 744969.4200
D 610 537.500000 33890.8800 95.8000
S 0 0.000000 0.0000 0.0000
H 51 52.220000 3531.0100 0.0000
T 0 0.000000 0.0000 0.0000
14469 14635.300000 741611.2700 0.0000
Other 326 300.500000 19482.1500 133.2500
---------------------------------------------------------
Total 39282 35164.020000 1680624.5700 745355.7200
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3832 3274.833333 143670.0400 281.2500
P 14783 11817.250000 481560.9300 500350.3800
D 0 0.000000 0.0000 0.0000
S 2 3.333333 250.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
18475 19107.625016 1143888.0200 0.0000
Other 3 2.836800 205.6400 0.0000
---------------------------------------------------------
Total 37095 34205.878482 1769574.6300 500631.6300
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1289 1468.250000 58684.0000 157.2500
P 16597 18164.250000 724088.2500 717545.0200
D 0 0.000000 0.0000 0.0000
S 1 3.000000 111.0000 111.0000
H 5 6.750000 401.7500 27.7500
T 0 0.000000 0.0000 0.0000
7648 24767.750000 1256986.9500 1256909.2100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 25541 44410.250000 2040281.2000 1974750.2300