CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 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 14392 45897.00000 1697587.2400 36.9869
Subtotal (Total Children Is Unduplicated) 14392 45897.00000 1697587.2400 36.9869
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 23.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.5800 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.7900 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.7200 28.7200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 33 62.000000 4650.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 63 115.000000 8586.0000 74.6609
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 32 51.000000 3825.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 13 24.000000 1800.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 21 38.500000 2887.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 30.500000 2287.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 15 32.000000 2400.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 33 59.000000 3274.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 72 127.500000 7076.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 543 1010.000000 75750.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1025 1844.530266 138300.7700 74.9789
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 189 337.500000 25312.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 616 1006.000000 75450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 185 328.500000 24637.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 332 582.000000 43542.7500 74.8157
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 635 1165.500000 64685.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1606 2806.500000 155760.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 245 436.000000 32700.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 443 730.500000 54787.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 37 37.000000 2659.5600 71.8800
OCTF-97168-OT RE-EVAL EST PLAN CARE 11 11.000000 561.5500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTF-97168TLGT-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 17 20.000000 1021.0000 51.0500
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 12.000000 612.6000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 28.000000 1429.4000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 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 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 20 17.000000 867.8500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SCREEN-T1023-SCREENING 45 45.000000 2250.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 28 26.000000 1327.3000 51.0500
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92521TL-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 24 24.000000 1225.2000 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 2 2.000000 102.1000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 4 4.000000 178.2000 44.5500
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 3 8.000000 420.5600 52.5700
Subtotal (Total Children Is Unduplicated) 3350 11103.53027 744711.9200 67.0698
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 11.000000 785.8400 71.4400
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 11.000000 275.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4756 35586.75000 1778835.5300 49.9859
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1558 8043.000000 402070.0000 49.9901
OCCT-97530-OT SESSION BY LICENSED OT 438 2305.500000 164704.9200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 49 168.250000 12019.7800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 193 1186.750000 67882.0800 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 5 10.500000 600.6000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 130 555.750000 39702.7800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 79 228.750000 16341.9000 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 6 22.500000 1287.0000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 25 205.000000 11726.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 431 2355.000000 167617.3000 71.1751
PHY-97110GT-PT SESSION BY LICENSED PT 48 142.500000 10180.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 117 752.525367 43014.3500 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 2.000000 114.3200 57.1600
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 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 137 622.500000 44471.4000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 52 82.000000 5858.0800 71.4400
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
PHY-97110TLHM-PT SESSION BY PT ASST 15 97.000000 5544.5200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 605 3652.750000 260952.4600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 97 305.750000 21842.7800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 33 194.750000 11139.7000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 252 1199.000000 85585.1200 71.3804
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 99 267.250000 19092.3400 71.4400
SPL-92508HA-GROUP SPL SESSION PER CHILD 2 1.500000 20.8200 13.8800
Subtotal (Total Children Is Unduplicated) 7154 58010.27537 3171721.9800 54.6752
-----------------------------------------------------------------------------------------------------------------------
Total 115010.805633 5614021.1400 48.8130
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 15750
-----------------------------------------------------------------------------------------------------------------------
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 6 6.000000 428.6400 428.6400
D 127 132.500000 7114.1500 0.0000
S 1682 1115.250000 50276.9500 0.0000
H 3396 2387.000000 98729.5100 98729.5100
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 257 368.000000 24535.0000 0.0000
---------------------------------------------------------
Total 5468 4008.750000 181084.2500 99158.1500
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 1815 1383.750000 58163.5000 0.0000
---------------------------------------------------------
Total 1815 1383.750000 58163.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 35 25.000000 925.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3872 3008.250000 132823.5200 0.0000
P 1 2.000000 150.0000 150.0000
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
19 22.500000 1635.8800 0.0000
Other 658 573.750000 24726.7800 0.0000
---------------------------------------------------------
Total 4585 3631.500000 160261.1800 150.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 36.750000 1595.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1271 1998.750000 82955.2500 0.0000
P 2039 3440.000000 136002.0400 134914.1500
D 131 211.250000 8735.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2440 8908.250000 450783.8600 0.0000
T 0 0.000000 0.0000 0.0000
289 335.500000 19297.1500 0.0000
Other 2 4.500000 321.4800 0.0000
---------------------------------------------------------
Total 6203 14935.000000 699691.0300 134914.1500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2646 1783.000000 65971.0000 36373.6400
P 0 0.000000 0.0000 0.0000
D 16 7.750000 286.7500 111.0000
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 1.000000 37.0000 0.0000
Other 12 4.750000 175.7500 0.0000
---------------------------------------------------------
Total 2677 1796.750000 66479.7500 36484.6400
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
13083 11604.250000 547442.4300 0.0000
Other 2 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 13085 11605.000000 547470.1800 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 4 4.000000 148.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 549 537.250000 25294.2500 0.0000
P 2848 2454.250000 103402.0000 103290.9700
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
3 2.750000 101.7500 0.0000
Other 55 29.500000 1091.5000 0.0000
---------------------------------------------------------
Total 3459 3027.750000 130037.5000 103290.9700
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1490 1628.250000 68585.7100 120.2500
P 2702 2877.750000 112061.7800 112061.7800
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
2021 7002.250000 391016.7300 0.0000
Other 170 301.000000 20243.5000 0.0000
---------------------------------------------------------
Total 6383 11809.250000 591907.7200 112182.0300
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 66 52.500000 2244.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 9637 8428.500000 355353.7500 0.0000
P 7 11.000000 719.7500 0.0000
D 57 53.750000 2900.9500 0.0000
S 7 14.500000 885.8000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5157 14087.500000 801704.4200 0.0000
Other 402 339.250000 13894.7500 0.0000
---------------------------------------------------------
Total 15333 22987.000000 1177703.9200 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 4 4.500000 249.7500 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
432 1436.750000 86343.6600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 436 1441.250000 86593.4100 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 10 6.500000 253.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 543 587.000000 32650.4800 196.7900
P 1700 1845.500000 83681.5000 83563.0000
D 0 0.000000 0.0000 0.0000
S 279 269.500000 11096.5000 521.9400
H 0 0.000000 0.0000 0.0000
T 1 1.000000 71.4400 0.0000
789 1583.250000 95549.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3322 4292.750000 223302.4300 84281.7300
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 19 28.500000 1916.0100 0.0000
P 670 728.250000 39823.6300 39823.6300
D 46 39.500000 2563.5800 0.0000
S 237 147.750000 5598.2500 0.0000
H 58 56.750000 2568.5100 0.0000
T 0 0.000000 0.0000 0.0000
4928 4752.750000 236683.7200 0.0000
Other 31 20.750000 1016.9400 0.0000
---------------------------------------------------------
Total 5989 5774.250000 290170.6400 39823.6300
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 54 64.250000 3745.5700 0.0000
P 650 722.750000 39873.7600 39873.8600
D 19 19.500000 1271.0200 0.0000
S 106 116.000000 8368.9200 0.0000
H 6 5.250000 354.5700 0.0000
T 0 0.000000 0.0000 0.0000
7464 7126.250000 334561.4700 0.0000
Other 76 49.000000 1906.2200 196.2500
---------------------------------------------------------
Total 8375 8103.000000 390081.5300 40070.1100
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.250000 83.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1248 1412.500000 69451.9100 0.0000
P 1768 1691.000000 68972.5000 67260.1400
D 0 0.000000 0.0000 0.0000
S 4 4.030266 264.2700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4293 4438.525367 269864.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7314 7548.305633 408635.9400 67260.1400
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1506 2302.750000 101700.2500 90.0000
P 2003 2973.500000 125226.9900 125072.3500
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 34 62.250000 2615.2500 2079.7100
1961 7161.500000 366735.1700 365760.3700
Other 135 164.500000 6086.5000 0.0000
---------------------------------------------------------
Total 5641 12666.500000 602438.1600 493002.4300