CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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 11829 15780.75000 583528.2500 36.9772
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 361 337.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7284 30626.25000 1132164.2500 36.9671
Subtotal (Total Children Is Unduplicated) 15475 46744.00000 1715692.5000 36.7040
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 13 14.000000 679.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.3700 19.3700
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 56.1900 14.0475
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 37.0300 9.2575
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 140.0400 28.0080
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
EVAL-96111-DEVELOPMENTAL EVALUATION 48 63.389200 3191.4600 50.3471
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 5.000000 250.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 243 388.389200 19419.4600 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.000000 675.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 22 37.836800 2837.7600 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 8 14.500000 1087.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 12.500000 937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 35.000000 1942.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 42 72.500000 4023.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 104 191.500000 14362.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 377 636.961063 47700.7297 74.8880
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 93.500000 7012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 162 264.935866 19870.1900 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 51 88.500000 6637.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 127 214.500000 16087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 273 512.500000 28443.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 607 1000.500000 55500.0000 55.4723
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 123 238.000000 17811.0000 74.8361
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 161 252.000000 18900.0000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 4 4.000000 121.4000 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 42 42.000000 2474.2200 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 46.8400 23.4200
NUTR-97802-NUTRITIONAL EVAL, INITIAL 2 5.000000 250.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 1 2.000000 100.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 3.397258 173.4300 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 15 15.000000 747.3400 49.8227
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 6.000000 303.1500 50.5250
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 6.303624 296.5400 47.0428
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 27 29.000000 1440.4500 49.6707
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 1777 4319.713011 276384.1897 63.9821
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 12 15.000000 1564.6100 104.3073
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 563 641.000000 32037.5000 49.9805
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 770 1803.250000 40162.5000 22.2723
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 185 173.000000 4325.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 603 747.750000 37375.0000 49.9833
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 922 938.250000 46912.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 123 105.250000 2631.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 385 472.000000 23600.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 750 588.000000 29400.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 50 70.000000 1750.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 163 187.000000 9350.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 465 279.000000 13950.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 5.250000 131.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 476 596.750000 29837.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 812 708.500000 35425.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 101 82.000000 2050.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 629 1040.750000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 4.750000 118.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1778 8852.250000 442317.5000 49.9667
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 662 3042.250000 152112.5000 50.0000
INTR-T1013-INTERPRETER 278 826.000000 41719.0000 50.5073
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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 9197 58018.00000 579884.6800 9.9949
OCCT-97530-OT SESSION BY LICENSED OT 147 616.509374 41857.7400 67.8947
OCCT-97530GT-OT SESSION BY LICENSED OT 29 76.250000 5447.3000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 38 141.740383 8101.4000 57.1566
OCCT-97530HMGT-OT SESSION BY OT ASST 2 2.000000 114.4000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 0.750000 53.5800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 141 541.759658 37241.5200 68.7418
PHY-97110GT-PT SESSION BY LICENSED PT 24 103.500000 7394.0400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 22 89.892233 5138.2400 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 2.500000 142.9000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 362 1470.883397 101710.1000 69.1490
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 88 276.000000 19627.4400 71.1139
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 2.500000 143.0000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 41.6400 13.8800
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 198 215.250000 7964.2500 37.0000
TRAV-TRAVS-Travel by mile 2697 188780.0000 83133.7900 0.4404
Subtotal (Total Children Is Unduplicated) 12578 271519.5350 1844837.3200 6.7945
-----------------------------------------------------------------------------------------------------------------------
Total 322583.248056 3836914.0097 11.8943
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21560
-----------------------------------------------------------------------------------------------------------------------
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 8019 31466.250000 112572.9400 112572.9400
D 1216 12004.500000 12624.4000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2983 13634.250000 43168.9500 43149.9500
722 758.250000 42375.0400 0.0000
Other 10 9.250000 399.2500 0.0000
---------------------------------------------------------
Total 12950 57872.500000 211140.5800 155722.8900
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 7 7.500000 235.0000 272.5000
H 0 0.000000 0.0000 0.0000
T 2611 11288.000000 54871.0300 54811.0400
282 1383.250000 6241.4600 0.0000
Other 2795 1513.500000 58235.0200 0.0000
---------------------------------------------------------
Total 5695 14192.250000 119582.5100 55083.5400
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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7940 42085.000000 214485.5400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7940 42085.000000 214485.5400 0.0000
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 2071 7470.500000 120055.0200 120082.7700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 69.000000 810.0000 660.0000
T 0 0.000000 0.0000 0.0000
3109 6940.500000 269637.7100 0.0000
Other 12 51.000000 1401.6400 1574.3200
---------------------------------------------------------
Total 5211 14531.000000 391904.3700 122317.0900
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 3984 20791.500000 135850.6900 135850.6900
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
2612 2269.500000 59716.1000 5335.3500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6596 23061.000000 195566.7900 141186.0400
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 7009 6988.250000 133657.0900 133657.0900
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
7651 5074.000000 163931.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14660 12062.250000 297588.8700 133657.0900
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 3352 9098.500000 172082.7500 171932.7500
D 29 20.250000 977.2500 0.0000
S 1 0.250000 9.2500 0.0000
H 15 30.000000 2250.0000 0.0000
T 0 0.000000 0.0000 0.0000
7138 3853.750000 139071.0000 50.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10535 13002.750000 314390.2500 171982.7500
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 8774 42404.250000 379447.1800 379447.1800
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 0 0.000000 0.0000 0.0000
3732 3756.000000 133115.2100 0.0000
Other 18 34.500000 2382.7500 0.0000
---------------------------------------------------------
Total 12524 46194.750000 514945.1400 379447.1800
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 3951 12105.500000 280299.1000 280099.1000
D 0 0.000000 0.0000 0.0000
S 31 45.500000 1102.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4689 4127.250000 168970.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8671 16278.250000 450372.3500 280099.1000
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 1384 5092.250000 92289.1900 92289.1900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 12.000000 488.6400 488.6400
T 0 0.000000 0.0000 0.0000
615 502.750000 19730.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2002 5607.000000 112508.7900 92777.8300
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 8 2.000000 74.0000 74.0000
D 6 5.500000 250.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3220 34903.250000 70203.5100 68201.1400
2813 1804.750000 59681.5400 39.7900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6047 36715.500000 130209.0500 68314.9300
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 1 0.500000 18.5000 0.0000
D 6 5.250000 194.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 49 87.000000 2446.9100 2446.9100
6166 5227.750000 132962.0300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6222 5320.500000 135621.6900 2446.9100
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 4 1.500000 55.5000 0.0000
S 1 1.000000 50.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 494 3557.750000 14496.5500 14496.5500
6559 4364.500000 160385.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7058 7924.750000 174987.7000 14496.5500
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 4454 6907.742190 76495.1700 76495.1700
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
5719 3708.005866 125490.8297 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10173 10615.748056 201985.9997 76495.1700
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 38 101.500000 1242.7800 1242.7800
H 0 0.000000 0.0000 0.0000
T 2440 10243.750000 116151.6000 116567.8500
2490 6774.750000 254230.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4968 17120.000000 371624.3800 117810.6300