CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 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 12635 16319.50000 603425.0000 36.9757
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 437 369.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7629 24150.50000 892784.2500 36.9675
Subtotal (Total Children Is Unduplicated) 16503 40839.75000 1496209.2500 36.6361
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 15 18.000000 873.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 38.7400 19.3700
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 6.000000 84.6400 14.1067
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 6.000000 55.9000 9.3167
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 6.000000 168.7600 28.1267
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 33.4000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 2 2.000000 41.7800 20.8900
EVAL-96111-DEVELOPMENTAL EVALUATION 41 51.250000 2562.5000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 37 69.750000 3487.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 287 499.000000 24950.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 19.500000 1462.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 9 14.000000 1050.0000 75.0000
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 8 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 14.500000 1087.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 30.000000 1665.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 23 39.500000 2192.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 73 129.468266 9710.1200 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 332 552.273732 41285.1200 74.7548
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 100.500000 7537.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 187 291.866667 21890.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 46 89.000000 6675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 154 266.359733 19976.9800 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 195 365.000000 20257.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 659 1067.500000 59246.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 75 145.802400 10935.1800 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 191 297.899900 22342.4925 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 43 43.000000 2533.1300 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 117.1000 23.4200
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 3 8.000000 400.0000 50.0000
OCTF-97168-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-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 18 18.000000 827.0000 45.9444
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 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 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 21 19.530852 972.0500 49.7700
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 5 5.000000 224.5800 44.9160
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1732 4258.701550 269413.9225 63.2620
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 9 16.000000 2198.9000 137.4313
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 2.000000 100.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 487 656.500000 26637.5000 40.5750
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 787 843.500000 42175.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 209 214.750000 5362.5000 24.9709
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 557 759.000000 35475.0000 46.7391
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1070 1188.000000 59350.0000 49.9579
CONIP-CONIP-CONSULT, ITDS PHONE 120 115.500000 2887.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 377 462.750000 23137.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 877 688.750000 34400.0000 49.9456
CONOP-CONOP-CONSULT, OT, PHONE 62 110.250000 2756.2500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 138 164.000000 8200.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 522 335.500000 16775.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 8 4.000000 100.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 471 544.750000 27237.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 962 857.500000 42862.5000 49.9854
CONSP-CONSP-CONSULT, SLP, PHONE 86 72.250000 1806.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 455 835.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 5.500000 137.5000 25.0000
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1810 10009.75000 499349.9100 49.8864
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 695 3249.750000 162487.5000 50.0000
INTR-T1013-INTERPRETER 234 863.250000 46191.0000 53.5083
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 8819 61822.00000 616914.1700 9.9789
OCCT-97530-OT SESSION BY LICENSED OT 176 798.970606 55667.8600 69.6745
OCCT-97530GT-OT SESSION BY LICENSED OT 34 105.000000 7476.2000 71.2019
OCCT-97530HM-OT SESSION BY OT ASST 28 141.378321 8074.5400 57.1130
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 188 852.689391 60394.2101 70.8279
PHY-97110GT-PT SESSION BY LICENSED PT 37 106.500000 7468.8800 70.1303
PHY-97110HM-PT SESSION BY PT ASST 14 73.562280 4204.8200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 449 2263.728442 156886.6000 69.3045
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 118 412.500000 29248.4200 70.9053
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 181 205.500000 7603.5000 37.0000
TRAV-TRAVS-Travel by mile 2886 222846.0000 98243.8100 0.4409
Subtotal (Total Children Is Unduplicated) 12477 311632.8290 2092153.3601 6.7135
-----------------------------------------------------------------------------------------------------------------------
Total 356731.280590 3857776.5326 10.8142
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21539
-----------------------------------------------------------------------------------------------------------------------
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 8779 33376.000000 132803.7500 132803.7500
D 1398 13568.500000 12516.9000 0.0000
S 23 15.500000 573.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 5361 21599.250000 73654.5000 73644.5000
2456 1549.250000 64310.8100 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 18018 70108.750000 283868.7100 206448.2500
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 1 1.000000 10.0000 10.0000
H 0 0.000000 0.0000 0.0000
T 2133 7523.000000 51731.8600 51514.3600
755 1226.000000 16412.7100 50.0000
Other 2679 1451.000000 60473.7500 0.0000
---------------------------------------------------------
Total 5568 10201.000000 128628.3200 51574.3600
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 176 2180.500000 4204.7600 4204.7600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 285 1911.250000 7213.9600 7213.9600
T 0 0.000000 0.0000 0.0000
7298 31254.250000 193172.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7759 35346.000000 204591.0300 11418.7200
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 2152 8196.000000 127513.3600 127513.3600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 17 53.000000 650.0000 650.0000
T 0 0.000000 0.0000 0.0000
2993 3319.000000 138332.2300 0.0000
Other 4 9.000000 250.0000 250.0000
---------------------------------------------------------
Total 5166 11577.000000 266745.5900 128413.3600
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 3706 21086.500000 120047.8700 120047.8700
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
3203 5670.250000 84238.9400 26444.9400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6909 26756.750000 204286.8100 146492.8100
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 3345 3318.750000 60989.9600 60989.9600
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
11447 8796.750000 236935.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14792 12115.500000 297925.7100 60989.9600
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 3304 9569.250000 178487.6300 178497.6300
D 15 12.000000 557.0000 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
7444 4077.452300 148427.4225 10.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10769 13670.702300 328372.0525 178507.6300
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 10335 69610.500000 529643.1400 529643.1400
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
4364 12942.250000 182745.1500 0.0000
Other 29 56.500000 3857.2500 0.0000
---------------------------------------------------------
Total 14728 82609.250000 716245.5400 529643.1400
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 4012 13148.500000 295493.3300 295493.3300
D 7 20.500000 341.3800 0.0000
S 35 55.000000 1317.1600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4518 3673.500000 140519.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8572 16897.500000 437671.1200 295493.3300
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 1223 6052.000000 86999.4100 86999.4100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 12.000000 120.0000 120.0000
T 0 0.000000 0.0000 0.0000
434 391.500000 16541.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1660 6455.500000 103660.9700 87119.4100
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 1 2.000000 111.0000 0.0000
S 1 0.750000 27.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 3005 35593.500000 68414.3700 66044.5300
2754 1784.500000 61237.5000 20.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5761 37380.750000 129790.6200 66064.5300
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 6 5.250000 231.2500 0.0000
S 2 2.750000 101.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 101 283.000000 4885.8700 4885.8700
6680 4255.750000 143973.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6789 4546.750000 149192.0300 4885.8700
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 1 0.250000 9.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 344 390.500000 17062.8500 17062.8500
7020 4626.250000 173593.3700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7365 5017.000000 190665.4700 17062.8500
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 4472 6567.376172 72986.7801 72986.7800
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
6014 4683.952118 123783.1900 105.9300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10486 11251.328290 196769.9701 73092.7100
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 17 24.250000 897.2500 0.0000
P 6 20.000000 740.0000 344.1000
D 3 3.250000 177.2500 0.0000
S 58 237.000000 2164.9700 2164.9700
H 0 0.000000 0.0000 0.0000
T 2384 9690.500000 109324.3700 109324.3700
3130 2726.000000 102515.2500 0.0000
Other 64 96.500000 3543.5000 2109.7500
---------------------------------------------------------
Total 5662 12797.500000 219362.5900 113943.1900