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: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 15 24.000000 888.0000 37.0000
Subtotal (Total Children Is Unduplicated) 16 24.500000 906.5000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 15 16.000000 314.3900 19.6494
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 18 19.000000 276.3100 14.5426
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 17 17.000000 165.0100 9.7065
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 17.000000 487.4700 28.6747
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 14 15.000000 293.9700 19.5980
EXIT-EXIT-EXIT ASSESSMENT 8 10.000000 500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 15.000000 1125.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 12 22.500000 1619.2500 71.9667
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 9.233733 692.5300 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 550.0000 68.7500
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 10 16.000000 1200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 16 27.000000 1316.0000 48.7407
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 245 494.201400 35197.6050 71.2212
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 491 879.703500 64969.9925 73.8544
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 79 160.500000 11572.5000 72.1028
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 200 357.273866 26178.7300 73.2736
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 83 154.500000 11417.5000 73.8997
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 134 231.000000 17225.0000 74.5671
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 176 346.000000 18960.0000 54.7977
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 509 887.500000 48112.2800 54.2110
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 103 197.669100 14825.1825 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 187 359.500000 26912.5000 74.8609
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 304.0000 304.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 4082.7900 272.1860
OCTF-97168-OT RE-EVAL EST PLAN CARE 8 7.195886 367.3500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 11 11.000000 561.5500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 23 24.000000 1174.1500 48.9229
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 28.357199 1447.6300 51.0498
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 4.000000 204.2000 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 326.6900 54.4483
PSTH-97162-PT EVAL MODERATE COMPLEXITY 16 16.000000 759.5700 47.4731
PSTH-97163-PT EVAL HIGH COMPLEXITY 13 16.897159 862.6000 51.0500
SCREEN-T1023-SCREENING 13 14.000000 650.0000 46.4286
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 71 73.000000 3747.0400 51.3293
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 8.000000 408.4000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 34 36.250000 1697.4000 46.8248
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 4 4.000000 178.2000 44.5500
Subtotal (Total Children Is Unduplicated) 1581 4566.281843 303301.8400 66.4221
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 15.000000 1666.8300 111.1220
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 944 5641.500000 281850.0000 49.9601
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 243 918.750000 45937.5000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 150.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 7 16.000000 160.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 406 1957.461082 133914.9300 68.4126
OCCT-97530GT-OT SESSION BY LICENSED OT 92 282.199888 19416.5700 68.8043
OCCT-97530HM-OT SESSION BY OT ASST 123 704.165035 38991.5400 55.3727
OCCT-97530HMGT-OT SESSION BY OT ASST 7 31.250000 1787.5000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 4 5.000000 357.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 427 2227.610027 151937.3700 68.2064
PHY-97110GT-PT SESSION BY LICENSED PT 74 219.250035 15355.2200 70.0352
PHY-97110HM-PT SESSION BY PT ASST 39 263.215181 14988.6000 56.9443
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 5 8.064556 460.9700 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1029 5485.576848 376319.7500 68.6017
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 185 680.750000 48360.9000 71.0406
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 39.500000 2259.4000 57.2000
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 0.750000 53.5800 71.4400
TRAV-TRAVS-Travel by mile 3 42.000000 18.6800 0.4448
Subtotal (Total Children Is Unduplicated) 2760 18551.79265 1134552.6800 61.1560
-----------------------------------------------------------------------------------------------------------------------
Total 23142.574495 1438761.0200 62.1694
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3913
-----------------------------------------------------------------------------------------------------------------------
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 2672 2698.000000 147689.1100 147689.1100
D 249 264.500000 15390.5000 50.0000
S 1 2.000000 150.0000 0.0000
H 167 204.750000 13159.5600 0.0000
T 247 246.000000 13031.0600 12897.3300
30 34.750000 2413.4400 0.0000
Other 13 22.500000 1570.5000 0.0000
---------------------------------------------------------
Total 3379 3472.500000 193404.1700 160636.4400
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 4 3.500000 185.7200 185.7200
H 0 0.000000 0.0000 0.0000
T 1235 1024.750000 57606.8400 57479.8400
14 17.250000 1178.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1253 1045.500000 58971.5000 57665.5600
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 36 35.750000 2177.6300 2177.6300
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
550 687.000000 49682.2700 0.0000
Other 13 21.500000 1612.5000 0.0000
---------------------------------------------------------
Total 599 744.250000 53472.4000 2177.6300
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 72 154.000000 10337.6900 3722.1000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 29.000000 1671.7600 0.0000
T 0 0.000000 0.0000 0.0000
92 160.000000 15186.7900 0.0000
Other 92 227.500000 15589.0600 1078.7600
---------------------------------------------------------
Total 264 570.500000 42785.3000 4800.8600
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 119 233.750000 12131.2400 12131.2400
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
12 36.000000 2312.6500 2312.6500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 131 269.750000 14443.8900 14443.8900
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 514 322.250000 20723.4000 20723.4000
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
1163 1087.000000 72693.5900 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 1678 1410.000000 93444.7400 20723.4000
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 416 900.124000 58548.4400 58405.5500
D 4 8.000000 600.0000 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
52 102.750000 7677.7500 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 479 1023.374000 67744.6900 58405.5500
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 349 883.000000 58516.5400 58947.8900
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 32 70.500000 4295.8000 4262.5500
198 438.750000 30145.5900 0.0000
Other 6 12.000000 861.0000 0.0000
---------------------------------------------------------
Total 585 1404.250000 93818.9300 63210.4400
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 1396 2201.250000 146713.0000 146522.9600
D 1 1.000000 71.4400 0.0000
S 8 11.000000 521.5300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1053 1913.250000 130517.8300 0.0000
Other 6 11.500000 794.2500 0.0000
---------------------------------------------------------
Total 2464 4138.000000 278618.0500 146522.9600
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 226 635.750000 41943.1900 41943.1900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 12.000000 821.5600 821.5600
T 0 0.000000 0.0000 0.0000
55 142.500000 9052.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 285 790.250000 51817.4400 42764.7500
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 133 170.500000 9217.6000 6760.5400
D 211 237.500000 12225.0000 130.0000
S 1 2.000000 150.0000 130.0000
H 179 241.000000 15506.3200 35.0000
T 745 1238.000000 75032.0900 70054.4000
393 724.500000 42710.5700 53.6100
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 1663 2614.000000 154860.0800 77163.5500
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 0 0.000000 0.0000 0.0000
S 12 14.000000 953.6400 0.0000
H 0 0.000000 0.0000 0.0000
T 33 34.000000 1735.2500 1735.2500
671 697.250000 44302.0300 0.0000
Other 70 70.000000 5017.4800 0.0000
---------------------------------------------------------
Total 786 815.250000 52008.4000 1735.2500
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 0 0.000000 0.0000 0.0000
S 2 2.000000 121.4400 0.0000
H 0 0.000000 0.0000 0.0000
T 124 134.740000 7202.2700 7202.2700
610 671.260000 43642.8600 0.0000
Other 41 42.000000 2814.6400 0.0000
---------------------------------------------------------
Total 777 850.000000 53781.2100 7202.2700
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 401 408.032475 26792.3500 26792.3500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 103 148.000000 10666.9800 0.0000
T 0 0.000000 0.0000 0.0000
1005 990.167969 61828.0800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1509 1546.200444 99287.4100 26792.3500
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 13 11.140472 760.9300 1155.6800
D 2 2.000000 130.5000 0.0000
S 4 4.000000 204.2000 204.2000
H 0 0.000000 0.0000 0.0000
T 624 2033.609579 103325.9600 99596.0100
220 398.000000 25881.2200 6864.2200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 863 2448.750051 130302.8100 107820.1100