CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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 15368 52915.00000 1957098.5000 36.9857
Subtotal (Total Children Is Unduplicated) 15368 52915.00000 1957098.5000 36.9857
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.7100 19.7100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 13.8700 13.8700
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.1600 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 44.8000 22.4000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 30 55.500000 4162.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 71 126.500000 9448.5000 74.6917
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 39 65.500000 4912.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 49 92.500000 6937.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 47.500000 3562.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 38 73.000000 5475.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 39 71.000000 3940.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 96 170.500000 9462.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 201 373.500000 27973.5000 74.8956
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1377 2417.166666 181120.8000 74.9310
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 51 93.000000 6975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 841 1372.500000 102937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 52 94.000000 7050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 531 934.500000 70012.5000 74.9197
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 285 537.500000 29831.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1935 3286.500000 182373.0000 55.4916
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 138 255.000000 19125.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 606 1008.000000 75561.0000 74.9613
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 765.8300 58.9100
OCTF-97168-OT RE-EVAL EST PLAN CARE 11 11.000000 561.5500 51.0500
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 10 10.000000 510.5000 51.0500
OCTF-97168TLGT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 26 27.000000 1378.3500 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 44 44.000000 2246.2000 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 12 10.500000 536.0250 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162TLGT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 18 19.000000 969.9500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 2.000000 102.1000 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163TLGT-PT EVAL HIGH COMPLEXITY 3 4.000000 204.2000 51.0500
SCREEN-T1023-SCREENING 20 20.000000 1000.0000 50.0000
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 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 14.000000 714.7000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 15 14.000000 714.7000 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 6 8.000000 356.4000 44.5500
SPCH-92610TL-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
SPCH-92610TLGT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUN 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 3403 11362.66667 765769.1750 67.3934
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 7.000000 5319.8100 759.9729
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 3.750000 93.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3612 27963.25000 1398162.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1952 9982.250000 499097.5000 49.9985
OCCT-97530-OT SESSION BY LICENSED OT 392 1889.250000 134968.0200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 101 328.750000 23485.9000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 161 932.750000 53353.3000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 16 89.250000 5105.1000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 74 285.750000 20413.9800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 116 390.750000 27915.1800 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 4 15.000000 858.0000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 40 256.000000 14643.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 430 2236.750000 159793.4200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 138 456.000000 32576.6400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 53 370.750000 21186.0700 57.1438
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 9.500000 543.0200 57.1600
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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-97110TL-PT SESSION BY LICENSED PT 59 236.750000 16913.4200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 80 314.250000 22450.0200 71.4400
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 6.000000 342.9600 57.1600
PHY-97110TLHM-PT SESSION BY PT ASST 14 73.750000 4215.5500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 596 3304.500000 235865.1600 71.3770
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 172 815.250000 58241.4600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 207 1286.500000 91907.5600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 121 543.250000 38788.3400 71.4005
SPL-92508-GROUP SPL SESSION PER CHILD 7 16.500000 229.0200 13.8800
Subtotal (Total Children Is Unduplicated) 6615 51813.50000 2866468.8800 55.3228
-----------------------------------------------------------------------------------------------------------------------
Total 116091.166666 5589336.5550 48.1461
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 16432
-----------------------------------------------------------------------------------------------------------------------
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 2.500000 133.2500 50.0000
D 128 133.500000 7035.7800 1301.4500
S 6309 4157.500000 184978.0200 337.5000
H 4380 2616.750000 108993.3600 108974.8600
T 1 0.250000 9.2500 0.0000
15 6.000000 222.0000 0.0000
Other 338 478.000000 30881.0000 7176.7500
---------------------------------------------------------
Total 11173 7394.500000 332252.6600 117840.5600
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 1376 1100.750000 49781.0000 0.0000
---------------------------------------------------------
Total 1376 1100.750000 49781.0000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 23 24.250000 910.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 4336 3141.750000 133745.7600 0.0000
P 224 187.750000 8548.8900 8548.8900
D 5 5.000000 336.8100 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
14 15.250000 988.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4602 3374.000000 144530.0300 8548.8900
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 109 154.750000 6537.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1812 3004.250000 118290.0000 64.7500
P 2098 3488.000000 129577.8800 127610.4600
D 26 41.750000 1544.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2329 8398.000000 425890.0800 0.0000
T 0 0.000000 0.0000 0.0000
556 644.750000 40990.3300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6930 15731.500000 722830.7900 127675.2100
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 16 10.750000 439.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 3285 2256.750000 86112.7700 58930.6100
P 0 0.000000 0.0000 0.0000
D 1 0.750000 27.7500 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 1.000000 37.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3303 2269.250000 86617.4200 58930.6100
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
12179 10052.000000 471033.4800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12179 10052.000000 471033.4800 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 41 40.500000 1611.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 435 346.000000 13363.7500 0.0000
P 3939 3270.000000 139048.5000 139781.1500
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
2 1.500000 55.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4417 3658.000000 154079.2500 139781.1500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 10.750000 397.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 151 156.000000 6314.5500 18.5000
P 3520 3928.500000 158323.5500 158823.0500
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 3 3.500000 129.5000 259.0000
1853 6016.250000 339961.1800 0.0000
Other 248 490.500000 34096.5000 0.0000
---------------------------------------------------------
Total 5783 10605.500000 539223.0300 159100.5500
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 80 64.250000 2528.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2871 2230.500000 86846.7500 18.5000
P 8313 6978.000000 294401.5000 293900.4900
D 58 45.000000 2135.0000 411.0000
S 120 231.500000 15579.4700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4042 11963.500000 698889.4750 0.0000
Other 2 0.500000 18.5000 18.5000
---------------------------------------------------------
Total 15486 21513.250000 1100398.9450 294348.4900
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 75.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 113 112.000000 6623.0000 0.0000
P 3 4.000000 225.0000 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
938 2062.500000 117060.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1055 2179.500000 123983.5300 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 4.250000 187.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 319 350.500000 19675.8500 0.0000
P 2376 2330.250000 103658.5600 103543.3200
D 1 1.000000 50.0000 0.0000
S 320 338.000000 14269.5000 9.2500
H 15 15.000000 985.8400 71.4400
T 0 0.000000 0.0000 0.0000
787 1699.750000 104928.3800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3822 4738.750000 243755.1300 103624.0100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 22.000000 951.7600 0.0000
U 0 0.000000 0.0000 0.0000
B 2773 2543.000000 123295.2400 0.0000
P 2196 1953.000000 92973.6000 92973.6000
D 257 202.250000 9917.9400 0.0000
S 77 61.000000 2680.7600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1325 1402.250000 73665.9300 0.0000
Other 12 9.500000 388.5000 101.7500
---------------------------------------------------------
Total 6665 6193.000000 303873.7300 93075.3500
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 7.000000 272.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3509 3164.750000 146241.0700 0.0000
P 2959 2589.750000 115603.2100 115584.7100
D 137 139.500000 6046.4200 0.0000
S 0 0.000000 0.0000 0.0000
H 1 0.250000 9.2500 9.2500
T 0 0.000000 0.0000 0.0000
1544 1674.000000 86608.0000 0.0000
Other 22 19.750000 1149.1500 101.7500
---------------------------------------------------------
Total 8180 7595.000000 355929.1000 115695.7100
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4467 3862.500000 166132.9800 0.0000
P 239 197.500000 7991.5000 7852.7620
D 0 0.000000 0.0000 0.0000
S 3 4.666666 274.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4397 4598.750000 281718.9700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9106 8663.416666 456117.4500 7852.7620
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 7.000000 276.2200 0.0000
U 0 0.000000 0.0000 0.0000
B 160 190.500000 7889.0400 0.0000
P 3896 4968.250000 203065.9700 200491.1800
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
1651 5857.000000 293699.7800 293699.7800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5714 11022.750000 504931.0100 494190.9600