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: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 5 4.250000 157.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 20 40.250000 1489.2500 37.0000
Subtotal (Total Children Is Unduplicated) 23 44.500000 1646.5000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 10 11.000000 213.4100 19.4009
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 17.000000 242.8900 14.2876
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.5000 23.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 18 19.000000 180.3300 9.4911
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 17.000000 482.0100 28.3535
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 44.7600 44.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 8.000000 168.6300 21.0788
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 5 7.110800 355.5400 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 7 9.110800 455.5400 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 21.000000 1555.5000 74.0714
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 16 29.163200 2128.7400 72.9940
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 3 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.500000 598.5000 70.4118
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 10 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.000000 832.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 20 37.500000 2081.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 230 460.000000 33480.0000 72.7826
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 583 1064.038934 78646.8400 73.9135
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 95 178.000000 12860.0000 72.2472
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 175 323.564133 23568.3500 72.8398
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 112 213.500000 15842.5000 74.2037
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 164 291.000000 21815.0000 74.9656
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 175 352.500000 18903.5100 53.6270
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 573 1015.000000 55289.1100 54.4720
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 93 186.000000 13950.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 160 251.000000 18825.0000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 3 3.000000 510.0000 170.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.000000 6501.8200 282.6878
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 2.602742 132.8700 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 262.8000 43.8000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 24 25.000000 1225.2000 49.0080
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 8.5500 8.5500
OCTH-97167-OT EVAL HIGH COMPLEXITY 13 22.000000 1123.1000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 5.696376 290.8000 51.0500
SCREEN-T1023-SCREENING 18 18.000000 900.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 53 54.000000 2695.8600 49.9233
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 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 10 13.000000 612.6000 47.1231
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 31.5200 31.5200
Subtotal (Total Children Is Unduplicated) 1614 4773.786985 320920.1300 67.2255
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 9.000000 4808.2600 534.2511
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 18 18.000000 900.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 931 4925.250000 245967.5000 49.9401
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 272 941.750000 47087.5000 50.0000
INTR-T1013-INTERPRETER 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 12.000000 120.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 374 1344.740617 92380.9400 68.6980
OCCT-97530GT-OT SESSION BY LICENSED OT 110 317.250000 22308.3500 70.3179
OCCT-97530HM-OT SESSION BY OT ASST 103 439.009614 24582.6900 55.9958
OCCT-97530HMGT-OT SESSION BY OT ASST 6 21.500000 1233.9700 57.3940
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 11.000000 785.8400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 360 1361.490342 92513.5300 67.9502
PHY-97110GT-PT SESSION BY LICENSED PT 76 260.250000 18287.6200 70.2694
PHY-97110HM-PT SESSION BY PT ASST 44 207.357767 11640.6700 56.1381
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 2.000000 114.3200 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 2 9.000000 642.9600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SENS-V5264-EARMOLD 2 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 914 3903.066771 270167.6000 69.2193
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 218 754.000000 53362.6600 70.7728
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 40.500000 2316.6000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 9 19.000000 1339.5000 70.5000
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 27.5600 13.7800
Subtotal (Total Children Is Unduplicated) 2676 14611.16511 891170.7100 60.9924
-----------------------------------------------------------------------------------------------------------------------
Total 19429.452096 1213737.3400 62.4689
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3947
-----------------------------------------------------------------------------------------------------------------------
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 1678 1710.250000 92109.5700 92049.5700
D 105 105.500000 6141.4900 0.0000
S 1 1.000000 50.0000 0.0000
H 198 231.500000 14648.2400 0.0000
T 621 639.250000 35066.9200 34609.6250
56 64.500000 4393.3100 0.0000
Other 15 27.500000 1887.0000 0.0000
---------------------------------------------------------
Total 2674 2779.500000 154296.5300 126659.1950
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 618 541.500000 34798.6100 34798.6100
107 81.000000 4861.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 725 622.500000 39660.2400 34798.6100
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
628 796.000000 56642.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 628 796.000000 56642.1200 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 18 46.250000 2694.7500 2783.6900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 20.000000 1040.3500 0.0000
T 0 0.000000 0.0000 0.0000
122 143.500000 15718.0700 0.0000
Other 67 142.000000 9689.4400 595.0600
---------------------------------------------------------
Total 212 351.750000 29142.6100 3378.7500
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 106 176.000000 10098.9800 10098.9800
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
3 3.500000 86.7800 86.7800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 109 179.500000 10185.7600 10185.7600
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 500 340.750000 21692.5900 21692.5900
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
980 977.250000 65871.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1480 1318.000000 87564.3400 21692.5900
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 228 443.750000 28732.4700 28732.4700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 29 58.000000 4350.0000 0.0000
T 0 0.000000 0.0000 0.0000
85 157.250000 10235.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 342 659.000000 43317.7200 28732.4700
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 217 468.000000 30925.6000 31637.6800
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 7 10.000000 376.8000 0.0000
231 538.500000 36993.6900 0.0000
Other 50 93.500000 6593.2500 0.0000
---------------------------------------------------------
Total 505 1110.000000 74889.3400 31637.6800
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 1024 1754.250000 114503.1000 114181.6200
D 0 0.000000 0.0000 0.0000
S 10 14.000000 979.7700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
901 1652.750000 112352.2900 240.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1935 3421.000000 227835.1600 114421.6200
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 190 476.750000 31446.8700 31446.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 3.000000 214.3200 214.3200
T 0 0.000000 0.0000 0.0000
48 108.750000 7487.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 239 588.500000 39149.0900 31661.1900
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 104 160.000000 8715.3300 6950.6600
D 143 174.250000 9259.5000 130.0000
S 3 5.000000 371.4400 112.5000
H 199 275.500000 18220.4000 328.9600
T 630 1040.000000 62353.8200 58016.6000
377 660.750000 39406.2400 9.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1456 2315.500000 138326.7300 65547.7200
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 2 4.000000 261.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 20 20.000000 1292.0000 1292.0000
767 844.250000 53643.2400 0.0000
Other 26 25.750000 1839.5800 0.0000
---------------------------------------------------------
Total 815 894.000000 57035.8200 1292.0000
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 1 1.000000 71.4400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 171 179.830000 10361.0500 10361.0500
519 572.420000 37720.9100 0.0000
Other 49 48.000000 3418.4000 0.0000
---------------------------------------------------------
Total 740 801.250000 51571.8000 10361.0500
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 182 176.866784 11804.0100 11804.0100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 109 163.548000 11702.4600 0.0000
T 0 0.000000 0.0000 0.0000
632 644.037312 42808.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 923 984.452096 66314.6400 11804.0100
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 3 5.000000 263.6300 219.0000
D 10 11.000000 737.2500 0.0000
S 7 12.250000 675.0600 675.0600
H 0 0.000000 0.0000 0.0000
T 611 2036.000000 103340.6900 103340.6900
255 544.250000 32788.8100 18219.3100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 886 2608.500000 137805.4400 122454.0600