CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 12252 36455.25000 1347996.5000 36.9767
Subtotal (Total Children Is Unduplicated) 12252 36455.25000 1347996.5000 36.9767
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 70.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 43.7400 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 29.3700 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 86.1600 28.7200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 62.6700 20.8900
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 15 28.500000 2137.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 45 81.500000 6073.5000 74.5215
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 29 46.000000 3450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 17 31.500000 2362.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 21.500000 1612.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 18 33.000000 2445.7500 74.1136
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 55.500000 3080.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 71 129.000000 7159.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 289 544.500000 40837.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 827 1454.000000 109020.7500 74.9799
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 95 173.500000 13012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 453 735.426134 55104.4600 74.9286
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 112 209.000000 15675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 241 433.000000 32475.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 400 735.000000 40792.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1143 1980.000000 109890.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 153 268.500000 20137.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 281 478.500000 35853.0000 74.9279
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 2 2.000000 60.7000 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 24 24.000000 1556.5100 64.8546
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 78.0100 26.0033
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 24 24.000000 1225.2000 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 35 35.000000 1786.7500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTF-97164TL-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 19 19.000000 969.9500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 12 12.000000 612.6000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 29 29.000000 1450.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 20 20.000000 1021.0000 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 15 15.000000 765.7500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 3 3.000000 146.6500 48.8833
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 21 21.000000 1072.0500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.1000 44.5500
Subtotal (Total Children Is Unduplicated) 2354 7741.926134 516929.1700 66.7701
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.250000 56.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4316 33251.00000 1661951.0000 49.9820
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1556 7165.250000 358262.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 425 2214.500000 158203.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 50 193.250000 13805.7800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 190 1078.000000 61661.3100 57.1997
OCCT-97530HMGT-OT SESSION BY OT ASST 16 30.000000 1716.0000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 76 308.500000 22039.2400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 102 322.000000 23003.6800 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 3 21.000000 1201.2000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 46 355.750000 20348.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 424 2392.000000 170884.4800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 62 219.250000 15663.2200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 93 530.250000 30309.0900 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 4.500000 257.2200 57.1600
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 2
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110TL-PT SESSION BY LICENSED PT 108 392.250000 28022.3400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 55 159.250000 11376.8200 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 13 102.000000 5830.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 624 3470.750000 247777.7000 71.3902
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 70 281.750000 20128.2200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 31.500000 1801.8000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 244 1228.500000 87764.0400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 132 533.250000 37908.8600 71.0902
SPL-92508HA-GROUP SPL SESSION PER CHILD 6 20.000000 277.6000 13.8800
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 6987 54308.75000 2980279.2100 54.8766
-----------------------------------------------------------------------------------------------------------------------
Total 98505.926134 4845204.8800 49.1869
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 13919
-----------------------------------------------------------------------------------------------------------------------
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 0.500000 18.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 199 208.000000 11400.5000 0.0000
S 712 562.250000 31616.4700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 2.250000 83.2500 0.0000
Other 80 133.750000 8725.0000 0.0000
---------------------------------------------------------
Total 993 906.750000 51843.7200 0.0000
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 1458 998.750000 42484.7500 0.0000
---------------------------------------------------------
Total 1458 998.750000 42484.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 67 35.000000 1295.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1725 1598.500000 80643.9000 0.0000
P 0 0.000000 0.0000 0.0000
D 2 2.000000 100.0000 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
22 24.000000 1682.9300 0.0000
Other 1406 916.250000 36707.1500 0.0000
---------------------------------------------------------
Total 3222 2575.750000 120428.9800 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 24.500000 906.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2661 4375.250000 174099.2500 0.0000
P 772 1276.750000 50876.3400 49369.5700
D 9 9.000000 333.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2371 8522.000000 430346.9300 0.0000
T 0 0.000000 0.0000 0.0000
192 237.750000 14512.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6018 14445.250000 671074.7400 49369.5700
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 9.000000 333.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2348 1541.000000 57017.0000 24341.3800
P 0 0.000000 0.0000 0.0000
D 1 0.500000 18.5000 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
26 12.000000 444.0000 0.0000
Other 30 23.000000 851.0000 0.0000
---------------------------------------------------------
Total 2416 1585.500000 58663.5000 24341.3800
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
10852 9543.750000 460844.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10852 9543.750000 460844.4500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 375 302.500000 11944.5000 0.0000
P 2480 2082.500000 88573.0000 88305.0000
D 2 2.500000 129.5000 0.0000
S 3 4.500000 318.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
14 9.500000 351.5000 0.0000
Other 299 172.250000 6673.2500 0.0000
---------------------------------------------------------
Total 3177 2575.750000 108064.2500 88305.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 368 401.000000 16178.5700 166.5000
P 3765 3893.250000 153489.1200 153695.6220
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 5 6.000000 277.5000 527.2500
2235 7394.750000 411360.0800 0.0000
Other 96 178.750000 11710.2500 0.0000
---------------------------------------------------------
Total 6469 11873.750000 593015.5200 154389.3720
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 73 55.750000 2062.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 8661 7459.250000 308249.7500 0.0000
P 68 96.250000 5756.5100 0.0000
D 31 27.500000 1384.8900 0.0000
S 15 24.500000 1168.9600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3949 12214.000000 699456.8800 0.0000
Other 401 296.000000 11424.0000 0.0000
---------------------------------------------------------
Total 13198 20173.250000 1029503.7400 0.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 23 30.000000 2045.2500 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
687 1839.750000 109660.9300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 710 1869.750000 111706.1800 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 601 616.250000 27850.7200 252.1000
P 1754 1889.250000 88516.6500 93304.4800
D 2 3.250000 120.2500 0.0000
S 18 21.250000 975.3200 101.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1004 1944.750000 117577.8000 0.0000
Other 14 9.750000 360.7500 0.0000
---------------------------------------------------------
Total 3393 4484.500000 235401.4900 93658.3300
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 34 31.750000 1588.0300 0.0000
U 0 0.000000 0.0000 0.0000
B 1937 1766.250000 87334.6900 1055.0000
P 1312 1254.500000 59858.8900 59840.3900
D 46 46.250000 3311.2200 0.0000
S 144 116.000000 6764.4800 1554.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1400 1424.750000 72041.4300 0.0000
Other 148 115.750000 5977.5800 0.0000
---------------------------------------------------------
Total 5021 4755.250000 236876.3200 62449.3900
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3179 2678.000000 123228.4500 1959.2500
P 1644 1437.750000 66788.8100 66669.8400
D 14 13.750000 810.7800 0.0000
S 8 6.500000 240.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1987 2066.250000 108775.5900 0.0000
Other 134 102.500000 4739.5800 0.0000
---------------------------------------------------------
Total 6969 6309.000000 304740.9600 68629.0900
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2731 2180.500000 90573.4600 0.0000
P 4 7.750000 286.7500 286.7500
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
4309 4386.676134 268576.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7045 6576.926134 359586.9300 286.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 725 955.500000 40454.7500 0.0000
P 2072 2771.750000 113867.5000 113939.1500
D 0 0.000000 0.0000 0.0000
S 2 2.500000 163.5500 51.0500
H 0 0.000000 0.0000 0.0000
T 34 104.000000 3639.0000 2577.9500
1673 5996.000000 302761.3000 302770.8000
Other 2 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 4509 9832.000000 460969.3500 419338.9500