CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 11202 15019.75000 555556.5000 36.9884
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 375 304.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7593 24037.50000 889082.2500 36.9873
Subtotal (Total Children Is Unduplicated) 15256 39361.75000 1444638.7500 36.7016
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 14 14.000000 679.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 62.2400 20.7467
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 57.6100 14.4025
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 38.4500 9.6125
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 141.8200 28.3640
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 62.6700 20.8900
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 22 26.250000 1312.5000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 6 12.000000 600.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 300 498.500000 24925.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 14 25.500000 1912.5000 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 11 15.000000 1125.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.766267 282.4700 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 9 16.500000 1237.5000 75.0000
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 7 12.500000 937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 35.500000 1970.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 37 62.500000 3468.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 93 166.298600 12312.7950 74.0403
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 330 578.296500 43248.7875 74.7865
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 47 81.500000 5612.3800 68.8636
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 165 269.300000 20197.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 41 71.500000 5362.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 145 259.000000 19425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 280 498.500000 27486.3800 55.1382
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 596 1005.500000 55805.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 92 161.830900 12137.3175 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 161 254.000000 18980.5000 74.7264
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 1 1.000000 30.3500 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.000000 2567.2400 65.8267
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 46.8400 23.4200
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 5.000000 250.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 1.804113 92.1000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 31 30.142801 1503.8400 49.8905
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 254.2000 50.8400
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 31 32.000000 1553.3500 48.5422
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 9.000000 459.4500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1724 4256.189181 268907.1400 63.1803
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 18 35.000000 7263.7900 207.5369
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 682 793.500000 39550.0000 49.8425
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 868 931.250000 46543.7500 49.9799
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 271 269.250000 6731.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 748 967.500000 48337.5000 49.9612
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 997 1323.000000 66150.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 108 115.750000 2881.2500 24.8920
CONOF-CONOF-CONSULT, OT, FACE TO FACE 437 559.000000 27950.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 645 569.500000 28475.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 59 90.500000 2262.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 180 232.250000 11612.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 523 343.500000 17175.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 22 13.250000 331.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 545 643.750000 32187.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 947 896.500000 44825.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 82 91.250000 2268.7500 24.8630
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 752 1552.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 14.250000 356.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2262 13823.25000 687384.6700 49.7267
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 702 3278.750000 163837.5000 49.9695
INTR-T1013-INTERPRETER 256 999.500000 51443.7500 51.4695
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10189 81294.00000 812505.0000 9.9946
OCCT-97530-OT SESSION BY LICENSED OT 226 1108.038910 77338.0400 69.7972
OCCT-97530GT-OT SESSION BY LICENSED OT 32 85.300112 6079.6000 71.2731
OCCT-97530HM-OT SESSION BY OT ASST 43 196.334963 11224.2100 57.1687
OCCT-97530HMGT-OT SESSION BY OT ASST 1 4.000000 228.8000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 179 943.360018 64808.0600 68.6992
PHY-97110GT-PT SESSION BY LICENSED PT 31 118.250000 8379.5600 70.8631
PHY-97110HM-PT SESSION BY PT ASST 25 127.460464 7072.1300 55.4849
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 8.250000 457.3100 55.4315
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 4 7.750000 553.6600 71.4400
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 2 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 512 3009.423161 205577.9000 68.3114
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 75 295.000000 21074.8000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 166 185.250000 6854.2500 37.0000
TRAV-TRAVS-Travel by mile 3050 253399.0000 111737.6500 0.4410
Subtotal (Total Children Is Unduplicated) 13714 368337.9176 2622819.7000 7.1207
-----------------------------------------------------------------------------------------------------------------------
Total 411955.856809 4336365.5900 10.5263
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21753
-----------------------------------------------------------------------------------------------------------------------
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 11187 40228.750000 151937.2900 151937.2900
D 1372 6721.250000 17624.2900 0.0000
S 2 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1342 5159.750000 17358.1700 17358.1700
411 312.000000 15810.4200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14314 52422.250000 202748.6700 169295.4600
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 12 12.000000 160.0000 160.0000
H 0 0.000000 0.0000 0.0000
T 3129 13025.750000 66084.1100 66084.1100
137 2364.250000 2107.8300 0.0000
Other 2844 1557.000000 54278.1300 0.0000
---------------------------------------------------------
Total 6122 16959.000000 122630.0700 66244.1100
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 1664 14583.500000 42010.4600 42010.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 54 452.250000 2245.3500 2245.3500
T 0 0.000000 0.0000 0.0000
6140 21139.000000 149761.1500 0.0000
Other 5 6.500000 451.1300 0.0000
---------------------------------------------------------
Total 7863 36181.250000 194468.0900 44255.8100
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 3138 11234.500000 186908.8700 186898.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 43.000000 430.0000 430.0000
T 0 0.000000 0.0000 0.0000
2828 3113.250000 130170.1800 0.0000
Other 11 31.000000 941.7200 941.7200
---------------------------------------------------------
Total 5989 14421.750000 318450.7700 188270.5900
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 4513 25885.500000 148730.0600 148730.0600
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
2504 2329.500000 53143.3900 2555.1400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 7017 28215.000000 201873.4500 151285.2000
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 7723 7673.750000 147479.5200 147479.5200
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
8524 6513.500000 184740.4100 0.0000
Other 230 173.250000 6410.2500 0.0000
---------------------------------------------------------
Total 16477 14360.500000 338630.1800 147479.5200
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 5695 14677.000000 285246.7300 285256.7300
D 18 16.250000 677.2500 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
7119 3999.626000 146272.7000 290.0000
Other 9 7.750000 277.5000 0.0000
---------------------------------------------------------
Total 12841 18700.626000 432474.1800 285546.7300
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 14615 96876.750000 722696.6000 722696.6000
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 261 6308.750000 21817.8500 21817.8500
0 0.000000 0.0000 0.0000
Other 12 22.000000 1672.0000 0.0000
---------------------------------------------------------
Total 14888 103207.500000 746186.4500 744514.4500
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 5437 17874.750000 409174.9000 409174.9000
D 2 3.000000 214.3200 0.0000
S 41 66.000000 1393.2400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5026 4677.000000 189886.2500 0.0000
Other 2 4.000000 261.0000 0.0000
---------------------------------------------------------
Total 10508 22624.750000 600929.7100 409174.9000
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 1660 8181.500000 111090.8700 111090.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 10.000000 407.2000 407.2000
T 0 0.000000 0.0000 0.0000
59 109.000000 6256.7900 308.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1721 8300.500000 117754.8600 111806.0700
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 2 3.000000 161.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4200 47088.250000 88208.6400 86564.2400
2353 1579.000000 48122.7400 14.2400
Other 3 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 6558 48671.250000 136529.3800 86578.4800
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 15 18.000000 779.0000 0.0000
S 18 13.750000 618.9400 92.5000
H 0 0.000000 0.0000 0.0000
T 70 70.500000 3395.3100 3395.3100
6885 5812.500000 133161.7700 0.0000
Other 25 18.750000 693.7500 0.0000
---------------------------------------------------------
Total 7013 5933.500000 138648.7700 3487.8100
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 1 1.750000 64.7500 64.7500
D 18 17.750000 1225.1800 0.0000
S 14 9.500000 325.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 460 2048.250000 17631.4500 17631.4500
7052 7087.750000 181784.9300 0.0000
Other 83 49.750000 1840.7500 0.0000
---------------------------------------------------------
Total 7628 9214.750000 202872.3100 17696.2000
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 6914 10057.115218 117864.0600 117864.0600
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
5453 4518.115591 114408.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12367 14575.230809 232272.7100 117864.0600
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 15 18.000000 752.6000 752.6000
H 0 0.000000 0.0000 0.0000
T 3548 13940.500000 189097.3900 189069.3900
2720 4206.500000 159936.0000 0.0000
Other 3 3.000000 110.0000 110.0000
---------------------------------------------------------
Total 6286 18168.000000 349895.9900 189931.9900