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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 13083 39831.50000 1472624.0000 36.9713
Subtotal (Total Children Is Unduplicated) 13083 39831.50000 1472624.0000 36.9713
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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 18 34.500000 2587.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 63 113.500000 8473.5000 74.6564
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 15.000000 1125.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 40 65.000000 4875.0000 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 23 41.500000 3112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 25.500000 1912.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 23 42.500000 3158.2500 74.3118
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 39 72.500000 4023.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 90 163.000000 9046.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 345 639.500000 47962.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1086 1895.000000 142027.5000 74.9485
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 108 196.000000 14700.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 570 915.926134 68641.9600 74.9427
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 140 256.500000 19237.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 336 598.500000 44887.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 488 890.000000 49285.5000 55.3770
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1459 2492.000000 138306.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 196 343.500000 25762.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 373 634.500000 47523.7500 74.8995
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 4 4.000000 121.4000 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 30 30.000000 1935.9100 64.5303
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) 2972 9732.926134 651886.2700 66.9774
-----------------------------------------------------------------------------------------------------------------------
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 1557 7170.250000 358512.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 426 2218.500000 158489.6400 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:Program Patients
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 625 3472.750000 247920.5800 71.3903
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) 6989 54319.75000 2980957.8500 54.8780
-----------------------------------------------------------------------------------------------------------------------
Total 103884.176134 5105468.1200 49.1458
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 14819
-----------------------------------------------------------------------------------------------------------------------
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 201 210.500000 11558.7500 0.0000
S 756 616.000000 35109.4700 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 101 165.250000 10736.5000 0.0000
---------------------------------------------------------
Total 1060 994.500000 57506.4700 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 1673 1177.250000 50637.7500 0.0000
---------------------------------------------------------
Total 1673 1177.250000 50637.7500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 68 37.000000 1369.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1864 1806.000000 91634.4000 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
24 27.000000 1907.9300 0.0000
Other 1480 1012.250000 41157.9000 0.0000
---------------------------------------------------------
Total 3438 2884.250000 136169.2300 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 2792 4585.000000 183114.2500 0.0000
P 828 1362.000000 54568.8400 53062.4600
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
225 273.250000 16752.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6238 14775.750000 686021.5900 53062.4600
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 9.000000 333.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2545 1735.250000 64204.2500 27088.6300
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 2613 1779.750000 65850.7500 27088.6300
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
11412 10176.000000 492035.9500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11412 10176.000000 492035.9500 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 11.500000 538.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 399 336.250000 13382.2500 0.0000
P 2713 2369.250000 101720.2500 101452.2500
D 2 2.500000 129.5000 0.0000
S 4 6.500000 468.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
16 10.250000 379.2500 0.0000
Other 319 190.750000 7357.7500 0.0000
---------------------------------------------------------
Total 3465 2927.000000 123976.0000 101452.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 377 415.250000 16967.8200 166.5000
P 3905 4116.750000 163448.8700 163655.3720
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
2263 7446.750000 415260.0800 0.0000
Other 132 241.250000 16021.5000 0.0000
---------------------------------------------------------
Total 6682 12226.000000 611975.7700 164349.1220
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 74 56.250000 2081.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 9029 7875.750000 327143.5000 0.0000
P 77 111.750000 6671.0100 1672.4000
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 427 317.250000 12210.2500 0.0000
---------------------------------------------------------
Total 13602 20627.000000 1050116.7400 1672.4000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 28 35.500000 2438.2500 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
702 1859.250000 110797.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 730 1894.750000 113235.8200 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 628 657.500000 29680.9700 252.1000
P 1866 2077.000000 97886.1500 102757.2300
D 2 3.250000 120.2500 0.0000
S 20 25.250000 1236.3200 101.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1012 1960.750000 118621.8000 0.0000
Other 15 10.250000 379.2500 0.0000
---------------------------------------------------------
Total 3543 4734.000000 247924.7400 103111.0800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 34 31.750000 1588.0300 0.0000
U 0 0.000000 0.0000 0.0000
B 2051 1892.500000 93358.4400 1055.0000
P 1440 1401.500000 66480.6400 66462.1400
D 46 46.250000 3311.2200 0.0000
S 148 119.000000 6932.4800 1572.5000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1415 1446.000000 73135.4300 0.0000
Other 154 121.500000 6190.3300 0.0000
---------------------------------------------------------
Total 5288 5058.500000 250996.5700 69089.6400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3476 3012.750000 138675.9500 2109.2500
P 1753 1578.500000 73434.5600 73315.5900
D 15 15.750000 960.7800 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
2022 2118.000000 111836.8400 0.0000
Other 137 105.500000 4887.5800 0.0000
---------------------------------------------------------
Total 7414 6841.250000 330193.4600 75424.8400
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3206 2777.000000 118754.9600 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
4419 4606.676134 283438.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7630 7393.426134 402630.4300 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 780 1051.750000 45074.2500 0.0000
P 2303 3221.750000 133865.0000 133982.9000
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 36 112.250000 3944.2500 2836.9500
1673 5996.000000 302761.3000 302770.8000
Other 6 10.000000 370.0000 0.0000
---------------------------------------------------------
Total 4801 10394.750000 486196.8500 439641.7000