CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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 18 36.500000 1350.5000 37.0000
Subtotal (Total Children Is Unduplicated) 18 36.500000 1350.5000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 35 35.000000 688.8300 19.6809
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.4900 23.4900
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 38 38.000000 529.1900 13.9261
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 41 41.000000 373.7000 9.1146
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 45 45.000000 1254.1300 27.8696
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 2 2.000000 76.9400 38.4700
AUDE-92585-AUD EVOKED RESPONSE (COMP) 1 1.000000 84.8400 84.8400
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 28 28.000000 624.1800 22.2921
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 3.000000 345.0000 115.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 3.000000 150.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 10 12.110800 605.5400 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 22.000000 1650.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 22 37.163200 2787.2400 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 12 21.000000 1536.0000 73.1429
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 6 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 20.500000 1537.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 13 15.500000 1162.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 20 38.000000 2109.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 76 150.277900 11251.3425 74.8702
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 470 905.818034 67792.3725 74.8410
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 27.500000 2062.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 242 459.500000 34204.7800 74.4391
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 50.922200 3819.1650 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 150 279.604267 20970.3200 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 100.500000 5577.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 413 788.500000 43475.8200 55.1374
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 58.439100 4382.9325 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 218 374.695200 28451.9500 75.9336
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 18.000000 4816.5700 267.5872
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 130.0800 43.3600
OCTH-97165GT-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 21 22.000000 1072.0500 48.7295
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 38 41.000000 2017.0000 49.1951
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 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 17 17.000000 867.8500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 10 10.000000 510.5000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 3 3.000000 123.1500 41.0500
SCREEN-T1023-SCREENING 21 22.000000 1100.0000 50.0000
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 79 79.000000 3934.8000 49.8076
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 24 24.000000 1210.2000 50.4250
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 23 26.500000 1250.7250 47.1972
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.1000 44.5500
Subtotal (Total Children Is Unduplicated) 1292 3892.530701 258371.0875 66.3761
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 15.000000 7988.8700 532.5913
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 4 4.000000 200.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 4 4.500000 112.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 3.000000 75.0000 25.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 7.000000 350.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 0.500000 12.5000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 5 4.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 724 4677.000000 233525.0000 49.9305
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 382 1646.750000 82302.5000 49.9787
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 7.000000 70.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 360 1885.959966 130590.7200 69.2436
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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
OCCT-97530GT-OT SESSION BY LICENSED OT 166 680.499996 47843.4800 70.3064
OCCT-97530HM-OT SESSION BY OT ASST 100 585.000000 33015.3900 56.4366
OCCT-97530HMGT-OT SESSION BY OT ASST 14 52.000000 2827.7600 54.3800
OCCT-97530TLGT-OT SESSION BY LICENSED OT 9 49.250000 3344.2400 67.9034
PHY-97110-PT SESSION BY LICENSED PT 409 2421.185190 168814.2800 69.7238
PHY-97110GT-PT SESSION BY LICENSED PT 105 463.110722 32983.1900 71.2210
PHY-97110HM-PT SESSION BY PT ASST 16 69.250000 3958.3300 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 36.658667 2095.4100 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 8.000000 571.5200 71.4400
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 2.000000 912.0000 456.0000
SENS-V5264-EARMOLD 7 12.000000 216.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 961 5526.565365 382091.4500 69.1372
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 334 1462.059912 102688.9100 70.2358
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.000000 204.4000 51.1000
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 33.000000 2357.5200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 2725 19665.53982 1239472.4100 63.0276
-----------------------------------------------------------------------------------------------------------------------
Total 23594.570519 1499193.9975 63.5398
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3465
-----------------------------------------------------------------------------------------------------------------------
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 2298 2301.750000 126977.9500 126929.8500
D 102 102.500000 6045.3800 393.9300
S 1 1.000000 71.4400 0.0000
H 336 377.000000 24529.1400 0.0000
T 230 228.500000 12826.1800 12433.3500
139 157.750000 10107.7600 0.0000
Other 12 21.500000 1412.0000 111.0000
---------------------------------------------------------
Total 3118 3190.000000 181969.8500 139868.1300
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 369 294.000000 21300.7900 21318.6500
7 8.500000 586.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 376 302.500000 21887.4200 21318.6500
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 21 21.000000 1470.8000 1470.8000
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 0 0.000000 0.0000 0.0000
601 720.000000 51504.5700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 622 741.000000 52975.3700 1470.8000
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 73 152.000000 10430.7400 4674.6100
D 18 25.500000 2982.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 16 34.000000 1922.6500 0.0000
T 0 0.000000 0.0000 0.0000
73 82.000000 8299.9000 153.1500
Other 208 506.250000 34233.0400 893.0000
---------------------------------------------------------
Total 388 799.750000 57868.8300 5720.7600
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 161 288.000000 18042.4700 18042.4700
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
14 30.000000 2105.4600 2105.4600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 175 318.000000 20147.9300 20147.9300
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 710 398.250000 26993.3500 26993.3500
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
1294 953.750000 65587.2100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2004 1352.000000 92580.5600 26993.3500
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 375 814.837100 55489.6025 55489.5900
D 10 20.000000 1500.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 13 26.000000 1950.0000 0.0000
T 0 0.000000 0.0000 0.0000
42 78.000000 5435.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 440 938.837100 64374.6025 55489.5900
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 1.000000 51.0500 0.0000
P 311 562.500000 36598.8200 38430.5300
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 2 1.250000 46.4300 71.4400
214 572.000000 40361.9300 0.0000
Other 5 9.500000 712.5000 0.0000
---------------------------------------------------------
Total 533 1146.250000 77770.7300 38501.9700
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 1871 3346.750000 223150.3500 223186.0700
D 9 4.500000 321.4800 0.0000
S 16 20.500000 1052.5500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1146 1993.250000 131737.3650 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3042 5365.000000 356261.7450 223186.0700
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 259 725.250000 48333.6700 48333.6700
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
33 69.250000 4476.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 292 794.500000 52810.5700 48333.6700
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 66 82.250000 4393.2000 3432.7900
D 107 135.250000 7223.8200 0.0000
S 1 1.000000 71.4400 0.0000
H 202 272.750000 18122.6200 0.0000
T 806 1455.750000 93767.8200 88146.6800
331 594.000000 36285.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1513 2541.000000 159864.0700 91579.4700
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 29 33.750000 1248.7500 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 12 11.750000 839.4200 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 27 27.000000 1350.0000 1350.0000
846 928.500000 57534.3600 0.0000
Other 31 30.250000 2010.9800 0.0000
---------------------------------------------------------
Total 945 1031.250000 62983.5100 1350.0000
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 3 3.000000 214.3200 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 108 115.850000 6008.5100 6008.5100
648 690.900000 45138.7400 0.0000
Other 18 18.000000 1243.0400 0.0000
---------------------------------------------------------
Total 777 827.750000 52604.6100 6008.5100
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 245 259.338000 17760.7200 17760.7200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 66 90.500000 6444.5400 0.0000
T 0 0.000000 0.0000 0.0000
962 974.895433 64030.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1273 1324.733433 88235.8900 17760.7200
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 3 2.442040 179.8000 179.8000
D 0 0.000000 0.0000 0.0000
S 7 8.500000 437.8200 437.8200
H 0 0.000000 0.0000 0.0000
T 704 2249.195646 113302.6100 113302.6100
347 661.862300 42938.0800 19596.7800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1061 2921.999986 156858.3100 133517.0100