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: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 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 41 66.250000 2451.2500 37.0000
Subtotal (Total Children Is Unduplicated) 42 66.750000 2469.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 19 19.000000 368.7100 19.4058
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 23 24.000000 345.6600 14.4025
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 22 23.000000 238.0600 10.3504
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 26 27.000000 728.7400 26.9904
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 50.1000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 16 16.000000 321.4400 20.0900
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.000000 460.0000 115.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.000000 125.0000 125.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 3 5.000000 250.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 4 6.500000 325.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.500000 862.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 18 32.000000 2361.0000 73.7813
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.500000 487.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 8.000000 570.7500 71.3438
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 11.500000 862.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 18.500000 1110.0000 60.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 15 25.500000 1415.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 168 337.031734 24937.3800 73.9912
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 606 1125.226268 83772.7700 74.4497
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 68 131.500000 9862.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 270 504.133333 37704.9000 74.7915
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 67 129.500000 9712.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 219 396.640267 29785.5200 75.0945
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 140 276.500000 15345.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 590 1075.500000 59138.8000 54.9873
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 89 173.697700 12998.0775 74.8316
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 232 379.100100 28432.5075 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 5168.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 12 12.000000 618.7500 51.5625
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 1.0500 1.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 29.000000 1480.4500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 6.000000 257.2300 42.8717
PSTH-97163-PT EVAL HIGH COMPLEXITY 11 11.000000 561.5500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 17 18.000000 850.0000 47.2222
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 77 77.469148 3911.0400 50.4851
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 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 13 12.500000 638.1250 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 5 5.000000 222.7500 44.5500
Subtotal (Total Children Is Unduplicated) 1648 5014.798550 339467.7100 67.6932
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 6.000000 4750.8300 791.8050
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 781 4567.250000 227842.5000 49.8861
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 252 979.500000 48925.0000 49.9490
INTR-T1013-INTERPRETER 1 0.750000 37.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 13.000000 130.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 364 1487.279394 103232.3300 69.4102
OCCT-97530GT-OT SESSION BY LICENSED OT 125 427.750000 30397.3100 71.0633
OCCT-97530HM-OT SESSION BY OT ASST 99 502.532519 28423.2500 56.5600
OCCT-97530HMGT-OT SESSION BY OT ASST 7 21.000000 1201.2000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 37.000000 2582.5500 69.7986
PHY-97110-PT SESSION BY LICENSED PT 384 1852.410273 127068.4999 68.5963
PHY-97110GT-PT SESSION BY LICENSED PT 68 240.000000 17166.7900 71.5283
PHY-97110HM-PT SESSION BY PT ASST 34 158.687720 9070.5900 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 3.000000 171.4800 57.1600
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SENS-V5050-IN EAR MONAURAL HEARING AID 2 4.000000 912.0000 228.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 956 4530.271555 314455.9698 69.4122
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 253 966.500000 68593.4000 70.9709
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 8 52.000000 3714.8800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 2613 15862.93146 988961.8397 62.3442
-----------------------------------------------------------------------------------------------------------------------
Total 20944.480011 1330899.2997 63.5442
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3896
-----------------------------------------------------------------------------------------------------------------------
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 1772 1806.750000 100938.6500 100938.6500
D 185 185.250000 10182.7700 0.0000
S 2 1.250000 80.6900 0.0000
H 146 176.000000 11476.8900 0.0000
T 1094 1112.500000 62721.3100 62393.2300
74 65.500000 3861.3600 0.0000
Other 4 6.500000 399.7500 0.0000
---------------------------------------------------------
Total 3277 3353.750000 189661.4200 163331.8800
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 0.750000 53.5800 -17.8600
H 0 0.000000 0.0000 0.0000
T 396 318.250000 22861.9600 22861.9000
139 130.500000 8956.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 536 449.500000 31872.1000 22844.0400
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 4.000000 240.8500 240.8500
T 0 0.000000 0.0000 0.0000
681 841.750000 60304.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 685 845.750000 60545.1600 240.8500
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 51 116.500000 7249.4200 1517.1800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 34.000000 1764.8000 0.0000
T 0 0.000000 0.0000 0.0000
128 153.000000 15153.5000 0.0000
Other 145 348.500000 23605.1300 0.0000
---------------------------------------------------------
Total 333 652.000000 47772.8500 1517.1800
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 115 206.250000 12933.9700 12933.9700
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
37 67.250000 3966.5900 3781.5900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 152 273.500000 16900.5600 16715.5600
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 309 176.750000 12384.5300 12384.5300
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
1379 1192.500000 81714.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1688 1369.250000 94098.6100 12384.5300
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 212 475.547800 31034.0750 31034.0600
D 12 24.000000 1800.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 17 34.000000 2550.0000 0.0000
T 0 0.000000 0.0000 0.0000
60 116.250000 8130.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 301 649.797800 43514.3250 31034.0600
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 275 504.500000 32707.9700 33036.2800
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 13 22.500000 1375.2800 35.7200
291 657.750000 45771.3300 47.8600
Other 69 134.500000 9132.0000 0.0000
---------------------------------------------------------
Total 648 1319.250000 88986.5800 33119.8600
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 1131 1819.000000 123420.9600 123420.9600
D 1 4.500000 321.4800 0.0000
S 8 12.000000 592.9700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
934 1969.750000 135273.1350 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2074 3805.250000 259608.5450 123420.9600
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 234 641.750000 42612.5900 42612.5900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 8.000000 485.7600 485.7600
T 0 0.000000 0.0000 0.0000
30 66.750000 4357.8000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 267 716.500000 47456.1500 43098.3500
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 62 83.000000 4176.2500 3194.1300
D 85 103.500000 5506.5000 0.0000
S 5 5.000000 357.2000 0.0000
H 176 246.500000 16391.9200 115.0000
T 569 961.500000 61909.7400 57723.9100
374 645.250000 38761.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1271 2044.750000 127102.8100 61033.0400
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 2 1.750000 206.0000 206.0000
D 3 2.500000 178.6000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 31 31.000000 1497.5400 1497.5400
737 857.750000 53014.5100 0.0000
Other 34 34.000000 2343.2000 0.0000
---------------------------------------------------------
Total 807 927.000000 57239.8500 1703.5400
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 158 156.710000 8005.7500 8005.7500
582 634.540000 42130.4400 0.0000
Other 36 35.500000 2343.1600 0.0000
---------------------------------------------------------
Total 779 829.750000 52693.6700 8005.7500
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 212 215.500000 14689.1300 14689.1300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 97 148.226267 10825.9400 0.0000
T 0 0.000000 0.0000 0.0000
676 687.455944 44860.7597 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 985 1051.182211 70375.8297 14689.1300
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 11 19.000000 957.3500 957.3500
H 0 0.000000 0.0000 0.0000
T 622 2076.000000 106447.2900 106447.2900
331 562.250000 35666.2000 10849.0100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 964 2657.250000 143070.8400 118253.6500