CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 22.750000 860.2500 37.8132
Subtotal (Total Children Is Unduplicated) 11 22.750000 860.2500 37.8132
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 8 8.000000 155.9800 19.4975
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 8.000000 114.5100 14.3138
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.7000 23.7000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 76.1900 9.5238
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 9.000000 265.1300 29.4589
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.000000 128.3600 21.3933
EVAL-96111-DEVELOPMENTAL EVALUATION 3 6.000000 300.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 13.000000 975.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 23 39.000000 2925.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 15.000000 1125.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 17 23.500000 1762.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 25 46.000000 2372.6300 51.5789
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 98 178.228534 13367.1400 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 495 915.383467 67714.7600 73.9742
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 25.000000 1875.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 271 504.806267 37365.4700 74.0194
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 61.000000 4575.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 142 259.999999 19170.0000 73.7308
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 133.000000 7381.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 456 836.680180 45774.2900 54.7094
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 77.000000 5775.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 234 408.000000 30570.7500 74.9283
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 4256.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 3.460725 176.6700 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 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 10 10.000000 510.5000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 29 29.000000 1480.4500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 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 4 4.000000 204.2000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 12 12.000000 600.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 53 55.000000 2723.9000 49.5255
SPCH-92523GT-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 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 7 7.000000 357.3500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 2.000000 51.0500 25.5250
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 97.8800 48.9400
Subtotal (Total Children Is Unduplicated) 1262 3809.559172 259452.6600 68.1057
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 13.000000 4820.5100 370.8085
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 4 3.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 581 3414.500000 170605.0000 49.9649
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 403 1719.000000 85880.0000 49.9593
INTR-T1013-INTERPRETER 2 3.500000 175.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 9 12.000000 120.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 303 1331.175955 90158.2900 67.7283
OCCT-97530GT-OT SESSION BY LICENSED OT 150 562.250000 39847.0700 70.8707
OCCT-97530HM-OT SESSION BY OT ASST 76 398.238289 22094.5500 55.4807
OCCT-97530HMGT-OT SESSION BY OT ASST 20 106.684090 6102.3300 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 40.500000 2893.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 354 1802.056830 122876.2500 68.1867
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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
PHY-97110GT-PT SESSION BY LICENSED PT 136 478.750000 33048.9000 69.0316
PHY-97110HM-PT SESSION BY PT ASST 16 105.388908 6024.0300 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 7 27.010322 1543.9100 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 1 3.750000 267.9000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 5.750000 410.7800 71.4400
SENS-V5264-EARMOLD 5 11.000000 198.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 778 4020.723400 273319.9100 67.9778
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 370 1526.071394 107930.6000 70.7245
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 7.750000 443.3000 57.2000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 2.000000 114.4000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 3 6.000000 428.6400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 7 32.000000 2286.0800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 3 14.000000 159.6200 11.4014
Subtotal (Total Children Is Unduplicated) 2433 15655.59919 972198.3900 62.0991
-----------------------------------------------------------------------------------------------------------------------
Total 19487.908360 1232511.3000 63.2449
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3325
-----------------------------------------------------------------------------------------------------------------------
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 1354 1347.000000 74215.7900 74215.7900
D 105 104.500000 5632.5600 0.0000
S 0 0.000000 0.0000 0.0000
H 330 366.500000 23466.1800 0.0000
T 607 607.500000 33994.1700 32727.8400
138 156.000000 10343.4700 0.0000
Other 4 7.000000 486.0000 0.0000
---------------------------------------------------------
Total 2538 2588.500000 148138.1700 106943.6300
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 275 238.750000 16420.4900 16420.4900
53 32.750000 2035.1000 0.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 329 273.500000 18566.5900 16420.4900
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 30 29.500000 1755.7600 1755.7600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.500000 162.5000 162.5000
T 0 0.000000 0.0000 0.0000
427 542.000000 39278.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 459 574.000000 41196.9500 1918.2600
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 77 185.000000 12097.7600 7734.7100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 22.000000 1100.0000 0.0000
T 0 0.000000 0.0000 0.0000
89 98.000000 10409.7500 0.0000
Other 82 198.500000 13314.7800 857.2800
---------------------------------------------------------
Total 254 503.500000 36922.2900 8591.9900
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 127 233.250000 14384.0900 14384.0900
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
10 20.000000 1309.3500 1309.3500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 137 253.250000 15693.4400 15693.4400
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 982 556.750000 36442.2400 36442.2400
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
987 764.750000 51694.4100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1969 1321.500000 88136.6500 36442.2400
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 211 580.250000 38851.4500 38851.4500
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 36 72.000000 5400.0000 0.0000
T 0 0.000000 0.0000 0.0000
63 112.250000 7385.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 311 766.500000 51787.2000 38851.4500
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 202 352.750000 21104.3200 21568.1800
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 93 199.000000 11922.3500 11235.3500
204 571.000000 40391.9100 0.0000
Other 13 25.500000 1873.5000 0.0000
---------------------------------------------------------
Total 512 1148.250000 75292.0800 32803.5300
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 1304 2566.250000 165879.0100 165879.0100
D 0 0.000000 0.0000 0.0000
S 21 31.500000 1361.6800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
798 1518.750000 103969.6400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2123 4116.500000 271210.3300 165879.0100
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 195 595.750000 39881.9900 39881.9900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 12.000000 803.7000 803.7000
T 0 0.000000 0.0000 0.0000
11 57.000000 3922.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 211 664.750000 44607.6900 40685.6900
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 53 71.750000 3839.2400 3289.6200
D 95 122.500000 6602.3200 0.0000
S 2 0.750000 27.7500 0.0000
H 95 123.000000 8064.7100 40.0000
T 705 1241.750000 77810.8300 71919.0400
413 768.000000 47293.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1363 2327.750000 143638.7600 75248.6600
Center 53
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 3 3.000000 171.4400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 18 18.000000 905.5000 800.0000
688 776.000000 49676.7000 0.0000
Other 26 26.000000 1621.6000 0.0000
---------------------------------------------------------
Total 735 823.000000 52375.2400 800.0000
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 10 9.000000 642.9600 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 103 107.750000 5682.7300 5682.7300
573 643.500000 42111.4900 0.0000
Other 23 20.750000 1343.0000 0.0000
---------------------------------------------------------
Total 709 781.000000 49780.1800 5682.7300
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 406 407.968159 27142.4600 27142.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 46 80.500000 5929.7300 0.0000
T 0 0.000000 0.0000 0.0000
703 655.440201 42416.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1155 1143.908360 75488.8700 27142.4600
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 1 1.000000 50.0000 50.0000
H 0 0.000000 0.0000 0.0000
T 549 1680.250000 85776.1200 85776.1200
343 520.750000 33850.7400 8893.4500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 893 2202.000000 119676.8600 94719.5700