CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 10992 14811.75000 547970.0000 36.9956
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 398 333.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7760 23884.00000 883249.5000 36.9808
Subtotal (Total Children Is Unduplicated) 14995 39029.00000 1431219.5000 36.6707
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 9 10.000000 485.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 2 2.000000 47.0000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 72.9000 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 6 6.000000 58.7400 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 7 7.000000 184.8800 26.4114
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 37.0600 12.3533
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 42 66.750000 3337.5000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 12 30.000000 1500.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 266 390.500000 19525.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 10.500000 787.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 19.000000 1425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 10.000000 750.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 11.500000 862.5000 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 4 7.000000 500.0000 71.4286
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 35.500000 1970.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 26 35.500000 1970.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 131 230.500000 17287.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 312 558.827160 41912.0370 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 58.000000 4350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 128 215.726532 16179.4900 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 75 137.000000 10275.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 134 239.038399 17927.8800 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 296 549.000000 30469.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 637 1053.500000 58441.5000 55.4737
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 80 153.000000 11475.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 164 268.230900 20117.3175 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 38 38.000000 2731.4400 71.8800
NURS-T1001-NURSING ASSESSMENT 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 1 4.000000 200.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 17 16.444662 839.5000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 7.400196 377.7800 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 6 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 24 25.000000 1250.7300 50.0292
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 2.000000 1.1600 0.5800
Subtotal (Total Children Is Unduplicated) 1698 4242.417849 269385.2645 63.4981
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 17 47.000000 7875.9700 167.5738
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 3 4.000000 162.6600 40.6650
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 548 586.250000 29212.5000 49.8294
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 850 881.000000 44025.0000 49.9716
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 256 237.500000 5937.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 681 830.500000 41525.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 943 986.000000 49225.0000 49.9239
CONIP-CONIP-CONSULT, ITDS PHONE 103 98.000000 2447.5000 24.9745
CONOF-CONOF-CONSULT, OT, FACE TO FACE 400 484.500000 24187.5000 49.9226
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 684 523.750000 26175.0000 49.9761
CONOP-CONOP-CONSULT, OT, PHONE 77 120.000000 3000.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 183 258.000000 12900.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 584 424.750000 18737.5000 44.1142
CONPP-CONPP-CONSULT, PT, PHONE 13 9.250000 231.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 434 455.000000 22750.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 870 703.000000 35150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 89 80.750000 2018.7500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 834 2073.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.250000 56.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 50 130.250000 6012.5000 46.1612
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2167 11834.25000 591047.1000 49.9438
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 687 2786.000000 139200.0000 49.9641
INTR-T1013-INTERPRETER 230 771.750000 37831.5000 49.0204
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 9624 61142.00000 611810.0000 10.0064
OCCT-97530-OT SESSION BY LICENSED OT 180 784.537233 55515.0200 70.7615
OCCT-97530GT-OT SESSION BY LICENSED OT 36 100.000000 6891.0100 68.9101
OCCT-97530HM-OT SESSION BY OT ASST 38 185.616081 10388.4400 55.9673
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 175 757.886616 53448.3900 70.5229
PHY-97110GT-PT SESSION BY LICENSED PT 35 127.250000 9072.8800 71.2996
PHY-97110HM-PT SESSION BY PT ASST 17 95.414627 5411.2000 56.7125
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 8.250000 471.5700 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 2.500000 178.6000 71.4400
SENS-V5060-BEHIND EAR HEARING AID 1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 4 5.000000 84.6500 16.9300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 465 2313.905236 161863.2200 69.9524
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 85 276.714586 19705.6000 71.2127
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 1.500000 85.8000 57.2000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 165 179.500000 6641.5000 37.0000
TRAV-TRAVS-Travel by mile 2977 213204.0000 94324.0300 0.4424
Subtotal (Total Children Is Unduplicated) 13075 303518.3244 2136257.0300 7.0383
-----------------------------------------------------------------------------------------------------------------------
Total 346789.742228 3836861.7945 11.0639
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 21437
-----------------------------------------------------------------------------------------------------------------------
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 5463 15621.750000 74203.5600 74203.5600
D 925 4981.250000 10801.3700 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3342 12059.000000 45241.7500 45241.7500
308 263.500000 13790.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10038 32925.500000 144037.0000 119445.3100
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 1907 7775.250000 34599.5800 34599.5800
571 2574.750000 10549.4100 0.0000
Other 3182 2117.250000 59090.6700 0.0000
---------------------------------------------------------
Total 5660 12467.250000 104239.6600 34599.5800
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 7 7.000000 358.5000 358.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 19 181.250000 587.6900 587.6900
T 0 0.000000 0.0000 0.0000
5716 25928.750000 157126.4100 0.0000
Other 3 4.500000 279.0000 0.0000
---------------------------------------------------------
Total 5745 26121.500000 158351.6000 946.1900
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.500000 18.5000 0.0000
P 2120 7145.750000 119443.2900 119283.2900
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
2859 2990.500000 123137.4400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4980 10136.750000 242599.2300 119283.2900
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 24 11.500000 425.5000 0.0000
P 3994 30693.000000 130868.2300 130868.2300
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
3143 3394.250000 64413.8700 4668.1200
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 7162 34099.000000 195716.8500 135536.3500
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 8399 8340.250000 167007.1500 167007.1500
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
5692 4120.500000 122975.3400 0.0000
Other 446 335.000000 12376.5000 0.0000
---------------------------------------------------------
Total 14537 12795.750000 302358.9900 167007.1500
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 4213 10569.000000 216059.3400 216050.3400
D 14 11.750000 623.7500 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
6482 3501.058060 126063.8545 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10709 14081.808060 342746.9445 216050.3400
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 9667 65339.000000 471316.3300 471316.3300
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
4814 31152.000000 215933.9400 0.0000
Other 29 53.000000 3833.5000 0.0000
---------------------------------------------------------
Total 14510 96544.000000 691083.7700 471316.3300
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 4452 13971.750000 336390.0300 336390.0300
D 5 4.500000 166.5000 0.0000
S 34 65.750000 1381.1000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5596 4731.750000 193596.7500 0.0000
Other 13 21.750000 889.5000 0.0000
---------------------------------------------------------
Total 10100 18795.500000 532423.8800 336390.0300
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 1193 3905.250000 84250.9400 84250.9400
D 1 1.250000 81.3000 81.3000
S 0 0.000000 0.0000 0.0000
H 2 6.000000 244.3200 244.3200
T 0 0.000000 0.0000 0.0000
22 51.000000 3211.4600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1218 3963.500000 87788.0200 84576.5600
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 4.000000 222.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3192 33928.000000 67310.0300 66164.6200
2079 1540.750000 41804.6000 114.1000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5273 35472.750000 109336.6300 66278.7200
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 7 6.000000 325.3200 0.0000
S 197 80.500000 3012.9400 0.0000
H 0 0.000000 0.0000 0.0000
T 123 475.500000 4456.8600 4456.8600
7195 4813.750000 136835.9200 0.0000
Other 56 43.500000 1600.2500 0.0000
---------------------------------------------------------
Total 7578 5419.250000 146231.2900 4456.8600
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 5 5.000000 219.4400 0.0000
S 162 111.500000 1808.9400 0.0000
H 0 0.000000 0.0000 0.0000
T 928 6755.750000 21963.3000 21963.3000
8414 10325.750000 176160.7300 0.0000
Other 157 117.750000 4356.7500 0.0000
---------------------------------------------------------
Total 9666 17315.750000 204509.1600 21963.3000
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 5061 7625.809546 88604.5300 88604.5300
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
6417 4510.624622 150717.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11478 12136.434168 239322.4300 88604.5300
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 11.000000 561.5500 561.5500
H 0 0.000000 0.0000 0.0000
T 2830 10673.750000 190582.8900 190582.8900
2916 3807.500000 144102.0500 85.8000
Other 27 22.750000 869.8500 102.1000
---------------------------------------------------------
Total 5784 14515.000000 336116.3400 191332.3400