CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 11686 15304.25000 565789.2500 36.9694
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 354 292.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7181 24355.25000 900164.5000 36.9598
Subtotal (Total Children Is Unduplicated) 15383 39952.00000 1465953.7500 36.6929
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 17 21.000000 970.0000 46.1905
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 39.4200 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 41.6100 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.1600 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 55.6600 27.8300
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 44.8000 22.4000
EVAL-96111-DEVELOPMENTAL EVALUATION 77 91.000000 4550.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 6.000000 300.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 326 567.500000 28375.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 9.000000 675.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 16 23.000000 1713.1600 74.4852
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 9.500000 712.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 12 19.500000 1462.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 10 15.500000 1162.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 56.500000 3135.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 56 96.000000 5328.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 62 104.271467 7585.3600 72.7463
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 340 565.946400 42180.5200 74.5309
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 53.500000 4012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 186 313.571733 23517.8800 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 32.000000 2400.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 151 272.500000 20362.5000 74.7248
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 156 283.000000 15706.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 646 1099.819720 61039.9945 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 77.500000 5812.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 170 280.500000 21037.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 56 57.000000 3357.8700 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 93.6800 23.4200
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 8 33.000000 1650.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 1.539275 78.5800 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 105.0900 35.0300
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 599.8400 49.9867
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 3.000000 150.0000 50.0000
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 127.8900 42.6300
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 4.000000 201.0500 50.2625
SCREEN-T1023-SCREENING 8 8.000000 400.0000 50.0000
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 31 31.000000 1582.5500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 5 5.000000 255.2500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
SPCH-92610GT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 1759 4201.648595 262528.5045 62.4823
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 13 22.000000 2091.5200 95.0691
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 463 531.250000 26500.0000 49.8824
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 766 875.250000 43762.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 281 294.500000 7362.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 469 572.500000 28593.7500 49.9454
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1103 1317.250000 65789.0000 49.9442
CONIP-CONIP-CONSULT, ITDS PHONE 137 131.250000 3231.2500 24.6190
CONOF-CONOF-CONSULT, OT, FACE TO FACE 305 391.750000 19587.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 712 620.750000 29825.0000 48.0467
CONOP-CONOP-CONSULT, OT, PHONE 56 129.500000 3187.5000 24.6139
CONPF-CONPF-CONSULT, PT, FACE TO FACE 147 169.500000 8475.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 456 352.000000 17575.0000 49.9290
CONPP-CONPP-CONSULT, PT, PHONE 19 13.000000 325.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 402 421.750000 21087.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 806 808.500000 40425.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 99 93.250000 2331.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 201 278.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 9.000000 225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1499 8306.000000 414500.0000 49.9037
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 919 4579.500000 228850.0000 49.9727
INTR-T1013-INTERPRETER 197 822.500000 42027.5000 51.0973
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 7295 53659.00000 536060.0100 9.9901
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 2
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
OCCT-97530-OT SESSION BY LICENSED OT 172 780.324045 53545.9200 68.6201
OCCT-97530GT-OT SESSION BY LICENSED OT 54 169.750000 12017.3900 70.7946
OCCT-97530HM-OT SESSION BY OT ASST 29 127.011711 7079.1100 55.7359
OCCT-97530HMGT-OT SESSION BY OT ASST 10 40.065910 2291.7700 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 108 507.193165 35339.1200 69.6759
PHY-97110GT-PT SESSION BY LICENSED PT 50 213.500000 15234.5800 71.3563
PHY-97110HM-PT SESSION BY PT ASST 9 51.361092 2935.8000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 9.739678 556.7200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 420 2163.776600 150470.8300 69.5408
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 181 780.428606 55191.4900 70.7195
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 0.750000 39.1700 52.2267
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 357.2000 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 3 57.500000 638.4800 11.1040
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 282 430.000000 15900.7200 36.9784
TRAV-TRAVS-Travel by mile 2220 179069.0000 78839.8400 0.4403
Subtotal (Total Children Is Unduplicated) 10936 258806.1508 1972392.8000 7.6211
-----------------------------------------------------------------------------------------------------------------------
Total 302959.799402 3700875.0545 12.2157
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 19703
-----------------------------------------------------------------------------------------------------------------------
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 6746 31138.250000 112344.7200 112344.7200
D 607 3650.250000 10240.4500 0.0000
S 24 7.250000 268.2500 0.0000
H 1 0.250000 9.2500 0.0000
T 2928 10286.250000 48005.4900 48005.4900
5084 3145.750000 127180.5600 0.0000
Other 80 27.750000 1026.7500 0.0000
---------------------------------------------------------
Total 15470 48255.750000 299075.4700 160350.2100
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 2358 7576.000000 61283.7300 61012.9500
292 280.500000 6889.8000 0.0000
Other 2474 1241.750000 49803.3900 0.0000
---------------------------------------------------------
Total 5124 9098.250000 117976.9200 61012.9500
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 1970 16525.750000 51198.2300 51198.2300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 124 1173.250000 2356.1300 2356.1300
T 0 0.000000 0.0000 0.0000
5111 7180.000000 133277.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7205 24879.000000 186831.6300 53554.3600
Center 04
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 1903 7052.500000 120104.9300 120104.9300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 14 45.000000 880.0800 870.0800
T 0 0.000000 0.0000 0.0000
3087 3073.250000 126102.8000 0.0000
Other 5 26.000000 860.0000 800.0000
---------------------------------------------------------
Total 5009 10196.750000 247947.8100 121775.0100
Center 05
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 4114 22805.250000 142453.3700 142453.3700
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
2427 1854.000000 59736.4200 5148.4200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6541 24659.250000 202189.7900 147601.7900
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 6736 6709.500000 144188.2500 144188.2500
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
8552 5424.000000 170211.9700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 15288 12133.500000 314400.2200 144188.2500
Center 07
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 3337 10862.500000 178907.5200 178907.5200
D 17 16.500000 838.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 15.500000 1105.5000 0.0000
T 0 0.000000 0.0000 0.0000
7379 3950.750000 144526.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10741 14845.250000 325377.5200 178907.5200
Center 09
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 7925 43202.500000 407114.9000 407114.9000
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 3872 19687.750000 182010.1600 182019.4100
30 25.250000 960.2500 0.0000
Other 10 20.000000 1500.0000 0.0000
---------------------------------------------------------
Total 11837 62935.500000 591585.3100 589134.3100
Center 10
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 3854 11633.750000 288094.4200 288094.4200
D 1 0.500000 18.5000 0.0000
S 36 48.000000 1306.8300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3998 3222.500000 122796.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7889 14904.750000 412216.5000 288094.4200
Center 51
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 1051 6673.000000 77949.7300 77942.4200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 18.000000 405.3700 405.3700
T 0 0.000000 0.0000 0.0000
439 314.000000 13382.0000 20.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1496 7005.000000 91737.1000 78367.7900
Center 52
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 4.000000 222.0000 111.7600
D 9 12.500000 662.5000 0.0000
S 158 142.750000 5207.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 3477 40125.500000 81458.0700 80048.1900
2084 1411.250000 47001.1200 86.8700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5730 41696.000000 134551.4400 80246.8200
Center 53
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 13 8.750000 392.6300 0.0000
S 7 2.500000 125.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 143 130.000000 6254.7600 4606.7600
5492 3146.249900 125196.9745 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5655 3287.499900 131969.3645 4606.7600
Center 54
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 50.0000 0.0000
P 1 1.000000 50.0000 50.0000
D 4 2.500000 161.3800 0.0000
S 1 1.000000 24.8300 0.0000
H 0 0.000000 0.0000 0.0000
T 435 440.500000 20732.6700 20732.6700
6611 4230.000000 181985.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7053 4676.000000 203004.6300 20782.6700
Center 55
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 5300 7875.979615 90388.1000 90388.1000
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
5242 3868.819887 107056.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10542 11744.799502 197444.1800 90388.1000
Center 57
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 3 4.000000 40.0000 40.0000
H 0 0.000000 0.0000 0.0000
T 2361 9138.750000 112529.4900 112519.4900
3699 3499.750000 131997.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6063 12642.500000 244567.1700 112559.4900