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: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 20 44.250000 1637.2500 37.0000
Subtotal (Total Children Is Unduplicated) 20 44.250000 1637.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 35 35.000000 688.8300 19.6809
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 38 38.000000 529.1900 13.9261
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 41 41.000000 373.7000 9.1146
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 45 45.000000 1254.1300 27.8696
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 2 2.000000 76.9400 38.4700
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 28 28.000000 624.1800 22.2921
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.000000 345.0000 115.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 5.000000 250.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 10 12.110800 605.5400 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 27.500000 2062.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 28 46.663200 3499.7400 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 14 25.000000 1836.0000 73.4400
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 6 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 23.000000 1725.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 16 20.000000 1500.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 16.500000 915.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 24 45.000000 2497.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 93 177.444567 13288.8425 74.8901
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 637 1188.214567 88962.3625 74.8706
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 32.000000 2400.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 315 574.596800 42837.0400 74.5515
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 34 63.422200 4756.6650 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 220 394.104267 29387.8200 74.5686
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 64 119.000000 6604.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 575 1047.000000 57638.2900 55.0509
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 64.439100 4832.9325 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 282 474.195200 35914.4500 75.7377
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 24 25.000000 6944.5700 277.7828
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 130.0800 43.3600
OCTH-97165GT-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 21 22.000000 1072.0500 48.7295
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 38 41.000000 2017.0000 49.1951
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 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 17 17.000000 867.8500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 10 10.000000 510.5000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 3 3.000000 123.1500 41.0500
SCREEN-T1023-SCREENING 21 22.000000 1100.0000 50.0000
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 79 79.000000 3934.8000 49.8076
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 24 24.000000 1210.2000 50.4250
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 23 26.500000 1250.7250 47.1972
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.1000 44.5500
Subtotal (Total Children Is Unduplicated) 1621 4876.690701 327765.8075 67.2107
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 15.000000 7988.8700 532.5913
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 4 4.000000 200.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 4.500000 112.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 3.000000 75.0000 25.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 7.000000 350.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 6 5.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 724 4677.000000 233525.0000 49.9305
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 382 1646.750000 82302.5000 49.9787
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 7.000000 70.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 360 1885.959966 130590.7200 69.2436
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
OCCT-97530GT-OT SESSION BY LICENSED OT 166 680.499996 47843.4800 70.3064
OCCT-97530HM-OT SESSION BY OT ASST 100 585.000000 33015.3900 56.4366
OCCT-97530HMGT-OT SESSION BY OT ASST 14 52.000000 2827.7600 54.3800
OCCT-97530TLGT-OT SESSION BY LICENSED OT 9 49.250000 3344.2400 67.9034
PHY-97110-PT SESSION BY LICENSED PT 409 2421.185190 168814.2800 69.7238
PHY-97110GT-PT SESSION BY LICENSED PT 105 463.110722 32983.1900 71.2210
PHY-97110HM-PT SESSION BY PT ASST 16 69.250000 3958.3300 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 36.658667 2095.4100 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 8.000000 571.5200 71.4400
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 2.000000 912.0000 456.0000
SENS-V5264-EARMOLD 7 12.000000 216.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 961 5526.565365 382091.4500 69.1372
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 334 1462.059912 102688.9100 70.2358
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.000000 204.4000 51.1000
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 33.000000 2357.5200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 2726 19666.53982 1239472.4100 63.0244
-----------------------------------------------------------------------------------------------------------------------
Total 24587.480519 1568875.4675 63.8079
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3795
-----------------------------------------------------------------------------------------------------------------------
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 2301 2305.750000 127229.2000 127181.1000
D 102 102.500000 6045.3800 393.9300
S 1 1.000000 71.4400 0.0000
H 341 383.000000 24979.1400 0.0000
T 230 228.500000 12826.1800 12433.3500
141 161.250000 10341.0100 0.0000
Other 14 23.500000 1523.0000 111.0000
---------------------------------------------------------
Total 3130 3205.500000 183015.3500 140119.3800
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 375 305.500000 22163.2900 22181.1500
8 10.500000 736.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 383 316.000000 22899.9200 22181.1500
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 21 21.000000 1470.8000 1470.8000
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
638 782.500000 56192.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 659 803.500000 57662.8700 1470.8000
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 73 152.000000 10430.7400 4674.6100
D 20 27.000000 3324.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 16 34.000000 1922.6500 0.0000
T 0 0.000000 0.0000 0.0000
88 97.000000 10798.9000 153.1500
Other 208 506.250000 34233.0400 893.0000
---------------------------------------------------------
Total 405 816.250000 60709.3300 5720.7600
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 162 289.500000 18125.7200 18125.7200
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
14 30.000000 2105.4600 2105.4600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 176 319.500000 20231.1800 20231.1800
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 711 399.750000 27076.6000 27076.6000
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
1403 1103.250000 75795.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2114 1503.000000 102872.0600 27076.6000
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 377 818.837100 55789.6025 55789.5900
D 11 22.000000 1650.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 14 28.000000 2100.0000 0.0000
T 0 0.000000 0.0000 0.0000
46 85.000000 5885.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 448 953.837100 65424.6025 55789.5900
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.000000 51.0500 0.0000
P 329 597.500000 38782.5700 40666.2800
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 2 1.250000 46.4300 71.4400
235 611.000000 42867.6800 0.0000
Other 5 9.500000 712.5000 0.0000
---------------------------------------------------------
Total 572 1220.250000 82460.2300 40737.7200
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 1871 3346.750000 223150.3500 223186.0700
D 9 4.500000 321.4800 0.0000
S 16 20.500000 1052.5500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1258 2205.250000 146213.8650 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3154 5577.000000 370738.2450 223186.0700
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 259 725.250000 48333.6700 48333.6700
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
40 74.250000 4783.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 299 799.500000 53117.3200 48333.6700
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 68 86.250000 4504.9200 3544.5100
D 113 147.250000 7889.8200 0.0000
S 1 1.000000 71.4400 0.0000
H 214 296.750000 19805.6200 0.0000
T 818 1479.750000 95423.8200 89602.6800
337 606.000000 37107.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1551 2617.000000 164802.7900 93147.1900
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 31 36.750000 1359.7500 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 12 11.750000 839.4200 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 27 27.000000 1350.0000 1350.0000
866 963.500000 59836.3600 0.0000
Other 31 30.250000 2010.9800 0.0000
---------------------------------------------------------
Total 967 1069.250000 65396.5100 1350.0000
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 3 3.000000 214.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 113 124.350000 6607.0100 6607.0100
660 710.900000 46541.2400 0.0000
Other 18 18.000000 1243.0400 0.0000
---------------------------------------------------------
Total 794 856.250000 54605.6100 6607.0100
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 253 275.338000 18960.7200 18960.7200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 79 116.500000 8394.5400 0.0000
T 0 0.000000 0.0000 0.0000
985 1014.555433 67005.1300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1317 1406.393433 94360.3900 18960.7200
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 4 3.942040 292.3000 292.3000
D 0 0.000000 0.0000 0.0000
S 7 8.500000 437.8200 437.8200
H 0 0.000000 0.0000 0.0000
T 704 2249.195646 113302.6100 113302.6100
493 862.612300 56546.3300 19596.7800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1208 3124.249986 170579.0600 133629.5100