CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 37 60.750000 2247.7500 37.0000
Subtotal (Total Children Is Unduplicated) 38 61.250000 2266.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 19 19.000000 368.7100 19.4058
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 23 24.000000 345.6600 14.4025
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 22 23.000000 238.0600 10.3504
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 26 27.000000 728.7400 26.9904
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 50.1000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 16 16.000000 321.4400 20.0900
AUDE-V5090-DISPENSING FEE PER HEARING AID 2 4.000000 460.0000 115.0000
BEHV-H0031HO-COMP BEHAVIORAL HEALTH ASSESSMENT 1 1.000000 125.0000 125.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 3 4.500000 225.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.500000 712.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 26.500000 1948.5000 73.5283
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.500000 487.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.000000 375.0000 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 7 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 17.000000 1026.7500 60.3971
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 18.000000 999.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 142 288.531734 21299.8800 73.8216
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 448 860.166667 64132.3000 74.5580
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 56 111.500000 8362.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 213 412.133333 30900.0000 74.9757
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 47 94.000000 7050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 157 297.500000 22350.0000 75.1261
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 118 235.000000 13042.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 421 810.000000 44575.8000 55.0319
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 138.197700 10335.5775 74.7883
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 181 302.922200 22719.1650 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.000000 3344.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 12 12.000000 618.7500 51.5625
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 1.0500 1.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 29.000000 1480.4500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 6 6.000000 257.2300 42.8717
PSTH-97163-PT EVAL HIGH COMPLEXITY 11 11.000000 561.5500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 16 17.000000 800.0000 47.0588
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 77 77.469148 3911.0400 50.4851
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 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 13 12.500000 638.1250 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 5 5.000000 222.7500 44.5500
Subtotal (Total Children Is Unduplicated) 1294 3998.420782 268737.9775 67.2110
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 6.000000 4750.8300 791.8050
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 2 2.000000 100.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 780 4563.250000 227642.5000 49.8860
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 252 979.500000 48925.0000 49.9490
INTR-T1013-INTERPRETER 1 0.750000 37.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 13.000000 130.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 364 1487.279394 103232.3300 69.4102
OCCT-97530GT-OT SESSION BY LICENSED OT 125 427.750000 30397.3100 71.0633
OCCT-97530HM-OT SESSION BY OT ASST 99 502.532519 28423.2500 56.5600
OCCT-97530HMGT-OT SESSION BY OT ASST 7 21.000000 1201.2000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 37.000000 2582.5500 69.7986
PHY-97110-PT SESSION BY LICENSED PT 384 1852.410273 127068.4999 68.5963
PHY-97110GT-PT SESSION BY LICENSED PT 68 240.000000 17166.7900 71.5283
PHY-97110HM-PT SESSION BY PT ASST 34 158.687720 9070.5900 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 3.000000 171.4800 57.1600
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 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
SENS-V5050-IN EAR MONAURAL HEARING AID 2 4.000000 912.0000 228.0000
SENS-V5264-EARMOLD 3 6.000000 108.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 956 4530.271555 314455.9698 69.4122
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 253 966.500000 68593.4000 70.9709
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 8 52.000000 3714.8800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 2612 15858.93146 988761.8397 62.3473
-----------------------------------------------------------------------------------------------------------------------
Total 19918.602243 1259766.0672 63.2457
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3537
-----------------------------------------------------------------------------------------------------------------------
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 1751 1775.750000 98984.1500 98984.1500
D 185 185.250000 10182.7700 0.0000
S 2 1.250000 80.6900 0.0000
H 140 167.500000 10907.6400 0.0000
T 1087 1101.500000 62081.5600 61753.4800
70 62.000000 3636.8600 0.0000
Other 3 5.500000 344.2500 0.0000
---------------------------------------------------------
Total 3238 3298.750000 186217.9200 160737.6300
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 1 0.750000 53.5800 -17.8600
H 0 0.000000 0.0000 0.0000
T 391 308.750000 22149.4600 22149.4000
138 128.500000 8845.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 530 438.000000 31048.6000 22131.5400
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 4 4.000000 240.8500 240.8500
T 0 0.000000 0.0000 0.0000
654 796.750000 56954.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 658 800.750000 57195.1600 240.8500
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 51 116.500000 7249.4200 1517.1800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 9 34.000000 1764.8000 0.0000
T 0 0.000000 0.0000 0.0000
100 121.000000 11408.7500 0.0000
Other 145 348.500000 23605.1300 0.0000
---------------------------------------------------------
Total 305 620.000000 44028.1000 1517.1800
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 115 206.250000 12933.9700 12933.9700
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 62.750000 3800.0900 3781.5900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 148 269.000000 16734.0600 16715.5600
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 309 176.750000 12384.5300 12384.5300
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
1259 1020.500000 69974.3300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1568 1197.250000 82358.8600 12384.5300
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 210 472.369900 30795.7325 30795.7200
D 7 14.000000 1050.0000 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
58 112.250000 7869.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 288 624.619900 41664.9825 30795.7200
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 244 447.000000 29312.2200 29559.4900
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 9 15.500000 984.3800 35.7200
267 612.750000 43000.8300 47.8600
Other 39 77.500000 5198.2500 0.0000
---------------------------------------------------------
Total 559 1152.750000 78495.6800 29643.0700
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 1131 1819.000000 123420.9600 123420.9600
D 1 4.500000 321.4800 0.0000
S 8 12.000000 592.9700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
866 1837.750000 126153.1350 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2006 3673.250000 250488.5450 123420.9600
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 234 641.750000 42612.5900 42612.5900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 8.000000 485.7600 485.7600
T 0 0.000000 0.0000 0.0000
28 64.750000 4227.3000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 265 714.500000 47325.6500 43098.3500
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 59 77.000000 3804.2500 2874.9100
D 82 97.500000 5173.5000 0.0000
S 5 5.000000 357.2000 0.0000
H 160 215.500000 14242.4200 115.0000
T 557 939.500000 60376.7400 56352.9100
369 635.250000 38128.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1232 1969.750000 122082.3100 59342.8200
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 2 1.750000 206.0000 206.0000
D 3 2.500000 178.6000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 31 31.000000 1497.5400 1497.5400
706 806.250000 49475.2600 0.0000
Other 34 34.000000 2343.2000 0.0000
---------------------------------------------------------
Total 776 875.500000 53700.6000 1703.5400
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 156 153.210000 7772.5000 7772.5000
574 620.040000 41042.9400 0.0000
Other 36 35.500000 2343.1600 0.0000
---------------------------------------------------------
Total 769 811.750000 51372.9200 7772.5000
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 209 209.500000 14239.1300 14239.1300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 77 109.000000 7933.9700 0.0000
T 0 0.000000 0.0000 0.0000
648 635.982343 41100.2397 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 934 954.482343 63273.3397 14239.1300
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 19.000000 957.3500 957.3500
H 0 0.000000 0.0000 0.0000
T 621 2072.000000 106247.2900 106247.2900
229 427.250000 26574.7000 10849.0100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 861 2518.250000 133779.3400 118053.6500