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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 29.750000 1100.7500 37.0000
Subtotal (Total Children Is Unduplicated) 11 29.750000 1100.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 10 10.000000 235.0000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 15 15.000000 218.7000 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 18 18.000000 176.2200 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 18 18.000000 516.9600 28.7200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 63.1400 63.1400
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 11 11.000000 229.7900 20.8900
EVAL-96111-DEVELOPMENTAL EVALUATION 3 6.000000 300.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 4 7.000000 350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 25 48.000000 3600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 15.000000 1125.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 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 10 15.000000 1125.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 25 45.500000 2475.2500 54.4011
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 241 478.500000 35655.6500 74.5155
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 449 848.672840 62946.2130 74.1702
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 78 155.500000 11322.5000 72.8135
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 198 354.273466 26501.2600 74.8045
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 84 161.000000 11905.0000 73.9441
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 145 255.461599 18738.5700 73.3518
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 156 309.500000 17177.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 491 908.000000 49785.2000 54.8295
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 100 200.000000 15000.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 197 339.269100 25445.1825 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.000000 6992.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 16 15.500000 722.3350 46.6023
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 25 25.500000 1250.7200 49.0478
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 82.1000 41.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 21 20.555338 1049.3500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 6.000000 300.7500 50.1250
PSTH-97161-PT EVAL LOW COMPLEXITY 11 9.750000 497.7250 51.0487
PSTH-97162-PT EVAL MODERATE COMPLEXITY 14 13.500000 689.1700 51.0496
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 8.599804 439.0200 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 8 9.000000 400.0000 44.4444
SPCH-92521-EVAL OF SPEECH FLUENCY 24 22.750000 1161.3750 51.0495
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 58 60.000000 3063.0000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 541.5500 49.2318
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 7 7.000000 357.3500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 1524 4506.832147 305875.9305 67.8694
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 7.000000 1303.1500 186.1643
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 4 5.000000 250.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 0.250000 12.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 2.500000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 639 3147.000000 157010.0000 49.8920
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 209 627.750000 31387.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 4.000000 40.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 374 1374.175533 95029.1700 69.1536
OCCT-97530GT-OT SESSION BY LICENSED OT 90 225.500000 15946.2500 70.7151
OCCT-97530HM-OT SESSION BY OT ASST 109 525.133916 29614.0600 56.3933
OCCT-97530HMGT-OT SESSION BY OT ASST 9 23.000000 1315.6000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 9.750000 696.5400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 446 1819.863384 128033.1800 70.3532
PHY-97110GT-PT SESSION BY LICENSED PT 73 192.500000 13528.1300 70.2760
PHY-97110HM-PT SESSION BY PT ASST 37 189.575372 10756.6484 56.7407
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 7 12.750000 728.7900 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
SENS-V5264-EARMOLD 3 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 933 4099.094764 289754.9000 70.6875
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 201 644.785414 45215.4700 70.1248
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 26.500000 1515.8000 57.2000
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 2 9.000000 514.8000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 1 77.000000 34.2600 0.4449
Subtotal (Total Children Is Unduplicated) 2342 13034.12838 823319.3884 63.1664
-----------------------------------------------------------------------------------------------------------------------
Total 17570.710530 1130296.0689 64.3284
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3518
-----------------------------------------------------------------------------------------------------------------------
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 1571 1582.750000 87061.5800 87011.5800
D 200 220.000000 12904.9800 0.0000
S 1 1.000000 71.4400 0.0000
H 124 137.750000 8930.7600 0.0000
T 890 910.250000 49991.5900 49475.8200
40 54.500000 3815.1500 0.0000
Other 3 6.000000 450.0000 0.0000
---------------------------------------------------------
Total 2829 2912.250000 163225.5000 136487.4000
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 1 1.000000 71.4400 71.4400
H 0 0.000000 0.0000 0.0000
T 796 663.750000 39832.0900 39832.0900
214 144.750000 7255.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1011 809.500000 47159.0200 39903.5300
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
529 668.500000 48288.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 529 668.500000 48288.8500 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 35 65.000000 4416.8700 1640.8300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 11 28.000000 1843.2000 0.0000
T 0 0.000000 0.0000 0.0000
86 92.500000 12116.7500 0.0000
Other 61 121.000000 8283.4600 0.0000
---------------------------------------------------------
Total 193 306.500000 26660.2800 1640.8300
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 112 167.250000 10087.1400 10087.1400
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
17 35.000000 1801.2500 1801.2500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 129 202.250000 11888.3900 11888.3900
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 522 320.000000 20502.3000 20502.3000
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
870 867.750000 62591.9600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1392 1187.750000 83094.2600 20502.3000
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 318 544.691940 35893.9155 35893.9100
D 3 6.000000 450.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 20.000000 1500.0000 0.0000
T 0 0.000000 0.0000 0.0000
36 72.000000 5400.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 367 642.691940 43243.9155 35893.9100
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 261 612.500000 40558.4400 40863.2800
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 4 8.000000 444.0000 0.0000
327 750.750000 51266.4400 225.0000
Other 71 138.000000 10350.0000 0.0000
---------------------------------------------------------
Total 663 1509.250000 102618.8800 41088.2800
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 1118 1676.750000 113284.0500 113284.0500
D 1 2.000000 142.8800 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
877 1721.250000 117320.7950 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1996 3400.000000 230747.7250 113284.0500
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 141 384.500000 25685.5700 25685.5700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 71.4400 71.4400
T 0 0.000000 0.0000 0.0000
32 99.500000 6548.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 174 485.000000 32305.6300 25757.0100
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 53 76.500000 3738.0600 2599.4600
D 175 197.250000 10154.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 92 119.500000 7522.5000 37.5000
T 475 799.000000 43058.9500 38729.3500
470 818.500000 51768.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1265 2010.750000 116242.6100 41366.3100
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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 17 17.000000 850.0000 850.0000
668 720.000000 47072.8900 0.0000
Other 8 8.000000 571.5200 0.0000
---------------------------------------------------------
Total 693 745.000000 48494.4100 850.0000
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 8 7.750000 362.7500 0.0000
S 5 8.000000 592.8800 0.0000
H 0 0.000000 0.0000 0.0000
T 157 167.000000 9727.1200 9727.1200
674 730.250000 47523.6900 0.0000
Other 10 10.000000 714.4000 0.0000
---------------------------------------------------------
Total 854 923.000000 58920.8400 9727.1200
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 229 238.250000 15693.4400 15693.4400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 93 156.000000 11293.2000 0.0000
T 0 0.000000 0.0000 0.0000
812 782.018590 51867.0684 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1134 1176.268590 78853.7084 15693.4400
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 2 3.000000 195.7500 400.0000
D 0 0.000000 0.0000 0.0000
S 2 2.000000 102.1000 102.1000
H 0 0.000000 0.0000 0.0000
T 22 47.500000 2932.1300 2848.8800
290 538.500000 35271.0200 6182.7700
Other 1 1.000000 51.0500 51.0500
---------------------------------------------------------
Total 317 592.000000 38552.0500 9584.8000