CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 Page: 1
List order: No List
Payclass Filters:GR
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 12610 19140.50000 707995.5000 36.9894
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 341 271.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7961 28265.25000 1045647.7500 36.9941
Subtotal (Total Children Is Unduplicated) 16673 47677.00000 1753643.2500 36.7817
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 30 31.000000 1503.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 39.0800 19.5400
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 6 7.000000 98.5100 14.0729
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 8.000000 74.0600 9.2575
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 7.000000 196.5900 28.0843
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 33.4000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 41.7800 20.8900
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 61 71.250000 3562.5000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 32 63.500000 3175.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 387 612.639800 30631.9900 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 17 27.836800 2087.7600 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 11 15.500000 1162.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 9 15.500000 1162.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 32 58.500000 3246.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 43 71.500000 3968.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 56 95.055433 6912.2375 72.7180
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 341 594.618767 44190.7275 74.3177
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 60.500000 4537.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 233 383.403200 28755.2400 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 20.077800 1505.8350 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 184 327.895733 24592.1800 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 140 263.500000 14624.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 799 1322.500000 73398.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 75.560900 5667.0675 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 214 363.304800 27197.8600 74.8624
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 63 63.000000 3711.3300 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 46.8400 23.4200
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 6.000000 300.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 6.000000 300.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 6 6.000000 293.5000 48.9167
OCTH-97167-OT EVAL HIGH COMPLEXITY 34 34.000000 1559.6900 45.8732
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 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-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
SPCH-92522GT-EVAL OF SPCH SOUND PROD 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 34 34.000000 1735.7000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 3.000000 153.1400 51.0467
Subtotal (Total Children Is Unduplicated) 1997 4715.643233 294146.4675 62.3767
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 31 55.000000 15038.6000 273.4291
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 634 695.250000 34312.5000 49.3528
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1012 1153.500000 57650.0000 49.9783
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 266 268.250000 6681.2500 24.9068
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 636 770.750000 38475.0000 49.9189
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1130 1344.500000 67138.0000 49.9353
CONIP-CONIP-CONSULT, ITDS PHONE 116 128.250000 3206.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 383 514.000000 25700.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 920 766.500000 38312.5000 49.9837
CONOP-CONOP-CONSULT, OT, PHONE 58 123.500000 3087.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 181 218.750000 10912.5000 49.8857
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 584 397.250000 19837.5000 49.9371
CONPP-CONPP-CONSULT, PT, PHONE 8 5.500000 137.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 530 613.750000 30662.5000 49.9593
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1022 1035.000000 51750.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 100 96.250000 2406.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 262 474.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 4.500000 112.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1631 10521.00000 525565.0000 49.9539
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 858 4221.750000 210662.5000 49.8993
INTR-T1013-INTERPRETER 267 959.500000 49526.1200 51.6166
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 Page: 2
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 8337 70666.00000 706591.3200 9.9990
OCCT-97530-OT SESSION BY LICENSED OT 194 1000.290033 70279.9200 70.2595
OCCT-97530GT-OT SESSION BY LICENSED OT 48 144.500000 10091.9700 69.8406
OCCT-97530HM-OT SESSION BY OT ASST 33 212.500000 12155.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.750000 157.3000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 154 711.064810 49765.0300 69.9866
PHY-97110GT-PT SESSION BY LICENSED PT 51 206.389278 14476.5500 70.1420
PHY-97110HM-PT SESSION BY PT ASST 13 105.250000 6016.0900 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 8.091322 462.5000 57.1600
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 463 2605.684634 183062.5100 70.2551
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 157 626.190088 44258.3100 70.6787
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 204 269.500000 9971.5000 37.0000
TRAV-TRAVS-Travel by mile 2541 219321.0000 96112.5200 0.4382
Subtotal (Total Children Is Unduplicated) 12130 320251.7102 2395137.9300 7.4789
-----------------------------------------------------------------------------------------------------------------------
Total 372644.353398 4442927.6475 11.9227
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21248
-----------------------------------------------------------------------------------------------------------------------
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 10726 37551.500000 175414.4600 175414.4600
D 951 9809.500000 10100.9900 237.5900
S 17 6.250000 231.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 1096 4878.750000 15082.7200 15082.7200
5678 3506.250000 146003.3200 150.0000
Other 45 22.750000 954.7500 150.0000
---------------------------------------------------------
Total 18513 55775.000000 347787.4900 191034.7700
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 2982 10959.750000 80169.6500 79688.8400
68 699.000000 1335.9600 0.0000
Other 2882 1536.250000 63928.5000 0.0000
---------------------------------------------------------
Total 5932 13195.000000 145434.1100 79688.8400
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 1665 13479.500000 45308.3000 45308.3000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 20 240.000000 697.6300 697.6300
T 0 0.000000 0.0000 0.0000
7888 21469.500000 211178.6700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9573 35189.000000 257184.6000 46005.9300
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 2861 10388.250000 169775.3500 169801.3500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 13 41.000000 718.8000 568.8000
T 0 0.000000 0.0000 0.0000
3473 3496.000000 144582.4200 0.0000
Other 3 8.000000 120.0000 120.0000
---------------------------------------------------------
Total 6350 13933.250000 315196.5700 170490.1500
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 5008 31156.750000 169843.3900 169843.3900
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
2638 2014.750000 64605.4500 4508.2000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7646 33171.500000 234448.8400 174351.5900
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 5821 5785.250000 116766.3500 116766.3500
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 0 0.000000 0.0000 0.0000
11001 7898.750000 218680.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 16822 13684.000000 335447.0900 116766.3500
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 4911 14739.500000 258053.7500 257963.7500
D 30 27.750000 1328.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 6 12.000000 900.0000 0.0000
T 0 0.000000 0.0000 0.0000
8709 4570.412900 166923.2175 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 13656 19349.662900 427205.7175 257963.7500
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 13181 67370.500000 648708.7800 648708.7800
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
338 6377.750000 29022.5600 0.0000
Other 9 70.000000 512.5800 0.0000
---------------------------------------------------------
Total 13528 73818.250000 678243.9200 648708.7800
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 4356 13618.750000 301667.1900 301667.1900
D 7 10.750000 238.9700 0.0000
S 33 42.500000 1260.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5182 4098.500000 155963.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9578 17770.500000 459129.4100 301667.1900
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 1270 7225.500000 91742.4600 91742.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 20.0000 20.0000
T 0 0.000000 0.0000 0.0000
860 686.750000 27658.7900 0.0000
Other 1 6.000000 60.0000 60.0000
---------------------------------------------------------
Total 2132 7920.250000 119481.2500 91822.4600
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 0 0.000000 0.0000 0.0000
D 5 8.000000 433.0000 0.0000
S 60 47.750000 1721.0000 9.2500
H 0 0.000000 0.0000 0.0000
T 3859 43716.750000 90511.2200 88561.3600
2542 1721.500000 58632.9500 26.7000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6466 45494.000000 151298.1700 88597.3100
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3 0.750000 34.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 28 23.500000 869.5000 0.0000
S 10 4.000000 200.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 59 58.500000 2944.2500 2869.2500
6144 3549.750000 139338.9800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6244 3636.500000 143386.9800 2869.2500
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 6 2.500000 126.9400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 379 395.000000 18914.6500 18914.6500
7001 4328.750000 183104.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7386 4726.250000 202146.1100 18914.6500
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 5343 9163.781458 87746.6200 87746.6200
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
7385 5719.159040 149738.9300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12728 14882.940498 237485.5500 87746.6200
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 42 152.000000 1583.0000 1583.0000
H 0 0.000000 0.0000 0.0000
T 3298 13988.750000 166729.0600 166729.0600
3220 5955.750000 220675.0300 114.4000
Other 1 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 6561 20098.250000 389051.8400 168426.4600