CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 22.750000 860.2500 37.8132
Subtotal (Total Children Is Unduplicated) 11 22.750000 860.2500 37.8132
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 8 8.000000 155.9800 19.4975
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 8 8.000000 114.5100 14.3138
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.7000 23.7000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 8 8.000000 76.1900 9.5238
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 8 9.000000 265.1300 29.4589
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 6 6.000000 128.3600 21.3933
EVAL-96111-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.000000 675.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 18 30.000000 2250.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 13 17.500000 1312.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 20 37.000000 2053.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 84 153.728534 11529.6400 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 369 701.727201 51905.5400 73.9683
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 14.000000 1050.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 200 387.961600 28602.1200 73.7241
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 56.500000 4237.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 103 190.999999 14155.0000 74.1099
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 62 110.500000 6132.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 356 664.680180 36328.2900 54.6553
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 70.000000 5250.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 185 321.500000 24083.2500 74.9090
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3952.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 3.460725 176.6700 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 10.000000 510.5000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 29 29.000000 1480.4500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 12 12.000000 600.0000 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 55.000000 2723.9000 49.5255
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 15 15.000000 765.7500 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 7 7.000000 357.3500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 2.000000 51.0500 25.5250
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 97.8800 48.9400
Subtotal (Total Children Is Unduplicated) 1011 3043.558239 206486.2100 67.8437
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 13.000000 4820.5100 370.8085
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 4 3.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 581 3414.500000 170605.0000 49.9649
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 402 1717.000000 85780.0000 49.9592
INTR-T1013-INTERPRETER 2 3.500000 175.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 9 12.000000 120.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 303 1331.175955 90158.2900 67.7283
OCCT-97530GT-OT SESSION BY LICENSED OT 150 562.250000 39847.0700 70.8707
OCCT-97530HM-OT SESSION BY OT ASST 76 398.238289 22094.5500 55.4807
OCCT-97530HMGT-OT SESSION BY OT ASST 20 106.684090 6102.3300 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 40.500000 2893.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 354 1802.056830 122876.2500 68.1867
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 2
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110GT-PT SESSION BY LICENSED PT 136 478.750000 33048.9000 69.0316
PHY-97110HM-PT SESSION BY PT ASST 16 105.388908 6024.0300 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 7 27.010322 1543.9100 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 1 3.750000 267.9000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 5.750000 410.7800 71.4400
SENS-V5264-EARMOLD 5 11.000000 198.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 777 4018.723400 273177.0300 67.9761
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 369 1524.571394 107823.4400 70.7238
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 7.750000 443.3000 57.2000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 2.000000 114.4000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 3 6.000000 428.6400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 7 32.000000 2286.0800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 3 14.000000 159.6200 11.4014
Subtotal (Total Children Is Unduplicated) 2431 15650.09919 971848.3500 62.0985
-----------------------------------------------------------------------------------------------------------------------
Total 18716.407427 1179194.8100 63.0033
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3072
-----------------------------------------------------------------------------------------------------------------------
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 1352 1344.000000 73990.7900 73990.7900
D 105 104.500000 5632.5600 0.0000
S 0 0.000000 0.0000 0.0000
H 320 352.000000 22407.9300 0.0000
T 603 600.500000 33547.1700 32280.8400
134 148.000000 9782.4700 0.0000
Other 3 6.000000 411.0000 0.0000
---------------------------------------------------------
Total 2517 2555.000000 145771.9200 106271.6300
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 274 236.750000 16270.4900 16270.4900
53 32.750000 2035.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 327 269.500000 18305.5900 16270.4900
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 30 29.500000 1755.7600 1755.7600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.500000 162.5000 162.5000
T 0 0.000000 0.0000 0.0000
385 477.000000 34403.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 417 509.000000 36321.9500 1918.2600
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 77 185.000000 12097.7600 7734.7100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 22.000000 1100.0000 0.0000
T 0 0.000000 0.0000 0.0000
82 91.000000 9655.7500 0.0000
Other 82 198.500000 13314.7800 857.2800
---------------------------------------------------------
Total 247 496.500000 36168.2900 8591.9900
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 127 233.250000 14384.0900 14384.0900
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
10 20.000000 1309.3500 1309.3500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 137 253.250000 15693.4400 15693.4400
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 979 555.250000 36335.0800 36335.0800
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
933 700.750000 47281.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1912 1256.000000 83616.8600 36335.0800
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 209 576.250000 38551.4500 38551.4500
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 34 68.000000 5100.0000 0.0000
T 0 0.000000 0.0000 0.0000
59 104.750000 6823.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 303 751.000000 50624.7000 38551.4500
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 183 318.250000 19274.9400 19686.8000
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 86 186.000000 11109.3500 10677.3500
193 550.000000 39011.9100 0.0000
Other 9 18.000000 1350.0000 0.0000
---------------------------------------------------------
Total 471 1072.250000 70746.2000 30364.1500
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 1304 2566.250000 165879.0100 165879.0100
D 0 0.000000 0.0000 0.0000
S 21 31.500000 1361.6800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
731 1385.250000 94659.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2056 3983.000000 261899.8300 165879.0100
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 195 595.750000 39881.9900 39881.9900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 12.000000 803.7000 803.7000
T 0 0.000000 0.0000 0.0000
11 57.000000 3922.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 211 664.750000 44607.6900 40685.6900
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 49 63.750000 3383.2400 2891.1800
D 88 109.500000 5880.8200 0.0000
S 2 0.750000 27.7500 0.0000
H 83 99.000000 6381.7100 40.0000
T 686 1205.750000 75404.0800 69692.2900
404 750.500000 46176.4100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1312 2229.250000 137254.0100 72623.4700
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 3 3.000000 171.4400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 18 18.000000 905.5000 800.0000
667 741.500000 47402.4500 0.0000
Other 26 26.000000 1621.6000 0.0000
---------------------------------------------------------
Total 714 788.500000 50100.9900 800.0000
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 10 9.000000 642.9600 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 103 107.750000 5682.7300 5682.7300
548 594.500000 38611.9900 0.0000
Other 23 20.750000 1343.0000 0.0000
---------------------------------------------------------
Total 684 732.000000 46280.6800 5682.7300
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 397 389.968159 25792.4600 25792.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 34 56.500000 4129.7300 0.0000
T 0 0.000000 0.0000 0.0000
676 609.439268 39055.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1107 1055.907427 68977.8000 25792.4600
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 1 1.000000 50.0000 50.0000
H 0 0.000000 0.0000 0.0000
T 549 1680.250000 85776.1200 85776.1200
267 419.250000 26998.7400 8893.4500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 817 2100.500000 112824.8600 94719.5700