CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 Page: 1
List order: No List
Payclass Filters:TPIN
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 7 5.000000 185.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 61 113.250000 4190.2500 37.0000
Subtotal (Total Children Is Unduplicated) 65 118.250000 4375.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 39.0800 19.5400
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 42.3200 14.1067
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 18.8700 9.4350
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 84.3800 28.1267
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 33.4000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.000000 460.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 3 3.750000 187.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 10 12.000000 600.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 12.500000 937.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 17.000000 1125.0000 66.1765
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 13.000000 825.0000 63.4615
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 12 22.500000 1687.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 19.500000 1082.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 20.000000 1110.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 116.329867 8724.7400 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 374 712.659734 52523.1300 73.7002
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 39.000000 2925.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 157 293.044666 20829.8200 71.0807
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 43.500000 3262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 142 267.500000 19522.5000 72.9813
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 82 126.000000 6993.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 375 678.500000 37336.8700 55.0285
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.000000 1650.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 143 264.000000 19800.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 4.859941 248.1000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 52.3700 26.1850
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 4.000000 153.1500 38.2875
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 5.000000 204.2000 40.8400
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 10 10.000000 482.2300 48.2230
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 7 8.000000 321.0300 40.1288
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
PSTH-97161GT-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 3 3.000000 129.5900 43.1967
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 9.000000 408.4000 45.3778
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 14 15.000000 700.0000 46.6667
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 36 34.175319 1689.5600 49.4380
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 23 25.000000 1158.8200 46.3528
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 5 8.000000 308.8300 38.6038
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) 940 2869.819527 190405.7200 66.3476
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 6.000000 6079.5000 1013.2500
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 210 827.500000 41375.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 698 3826.750000 191338.1600 50.0002
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 30.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 127 488.638439 32663.1200 66.8452
OCCT-97530GT-OT SESSION BY LICENSED OT 209 935.314110 64233.7100 68.6761
OCCT-97530HM-OT SESSION BY OT ASST 34 130.257168 6998.1100 53.7253
OCCT-97530HMGT-OT SESSION BY OT ASST 39 154.090210 8813.9600 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 9 30.000000 2143.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 166 602.750000 40996.7900 68.0162
PHY-97110GT-PT SESSION BY LICENSED PT 226 1058.340000 71735.9100 67.7815
PHY-97110HM-PT SESSION BY PT ASST 10 71.000000 4058.3600 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 20.677923 1181.9500 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 2.750000 196.4600 71.4400
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 1000.0000 500.0000
SENS-V5264-EARMOLD 4 6.000000 94.0600 15.6767
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 397 1597.508958 110483.4097 69.1598
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 593 2857.708707 194860.2200 68.1876
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 17.250000 986.7000 57.2000
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 22.000000 1571.6800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.500000 35.7200 71.4400
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 Page: 2
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Subtotal (Total Children Is Unduplicated) 2012 12664.03552 781076.0197 61.6767
-----------------------------------------------------------------------------------------------------------------------
Total 15652.105042 975856.9897 62.3467
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2737
-----------------------------------------------------------------------------------------------------------------------
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 1468 1426.500000 80398.9400 80398.9400
D 36 35.750000 2045.8300 0.0000
S 2 2.000000 142.8800 0.0000
H 569 589.250000 37454.9700 0.0000
T 897 887.250000 52024.4700 51554.8500
283 302.000000 18956.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3255 3242.750000 191023.1700 131953.7900
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 152 136.500000 9060.0600 9060.0600
171 142.750000 11339.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 323 279.250000 20399.5900 9060.0600
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 2 2.000000 17.0400 17.0400
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
121 134.000000 8734.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 123 136.000000 8751.3100 17.0400
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 66 161.750000 9781.8900 4036.0300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 35.000000 1771.4400 0.0000
T 0 0.000000 0.0000 0.0000
34 41.750000 3044.2500 0.0000
Other 39 99.000000 6891.5700 908.3300
---------------------------------------------------------
Total 151 337.500000 21489.1500 4944.3600
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 109 208.000000 11697.0300 11697.0300
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
21 44.250000 2776.7700 2776.7700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 130 252.250000 14473.8000 14473.8000
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 1040 581.500000 39426.7200 39426.7200
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
1054 820.750000 55771.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2094 1402.250000 95198.5300 39426.7200
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 223 535.000000 35758.4600 35758.4600
D 0 0.000000 0.0000 0.0000
S 1 1.250000 46.2500 0.0000
H 4 8.000000 600.0000 0.0000
T 0 0.000000 0.0000 0.0000
101 126.750000 6589.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 329 671.000000 42994.4600 35758.4600
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 229 418.250000 25367.2700 26157.7800
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
265 707.500000 47170.5800 0.0000
Other 14 25.500000 1815.0000 0.0000
---------------------------------------------------------
Total 508 1151.250000 74352.8500 26157.7800
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 477 454.750000 30784.8300 30783.9500
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
586 1065.750000 70751.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1063 1520.500000 101535.9700 30783.9500
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 60 183.000000 12716.3800 12716.3800
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
9 27.500000 1916.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 69 210.500000 14632.8800 12716.3800
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 25 42.250000 2388.1500 2240.9700
D 0 0.000000 0.0000 0.0000
S 4 4.000000 285.7600 0.0000
H 50 59.750000 4105.0200 0.0000
T 598 970.750000 60684.8900 55713.9400
477 787.500000 48113.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1154 1864.250000 115577.6100 57954.9100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 13 5.750000 212.7500 0.0000
P 11 10.340000 739.5200 1182.3200
D 21 21.000000 1157.2000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 19 19.000000 971.4400 971.4400
698 749.750000 46788.3300 0.0000
Other 27 26.500000 1893.1600 0.0000
---------------------------------------------------------
Total 789 832.340000 51762.4000 2153.7600
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 28 28.250000 2018.1800 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 141 140.170000 8400.3900 8400.3900
742 770.080000 49342.0800 0.0000
Other 28 27.000000 1928.8800 0.0000
---------------------------------------------------------
Total 939 965.500000 61689.5300 8400.3900
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 433 385.500000 25704.5500 25704.5500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 50 80.000000 5637.9400 0.0000
T 0 0.000000 0.0000 0.0000
712 645.015042 42541.6497 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1195 1110.515042 73884.1397 25704.5500
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 7 4.750000 175.7500 175.7500
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 422 1377.250000 69123.9800 69123.9800
200 294.250000 18791.8700 3424.8700
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 629 1676.250000 88091.6000 72724.6000