CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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 5 4.250000 157.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 19 38.750000 1433.7500 37.0000
Subtotal (Total Children Is Unduplicated) 22 43.000000 1591.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 10 11.000000 213.4100 19.4009
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 16 17.000000 242.8900 14.2876
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 1.000000 23.5000 23.5000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 18 19.000000 180.3300 9.4911
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 16 17.000000 482.0100 28.3535
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 44.7600 44.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 8 8.000000 168.6300 21.0788
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 4 5.110800 255.5400 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 7 9.110800 455.5400 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 20.000000 1500.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 13 23.163200 1678.7400 72.4744
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.500000 598.5000 70.4118
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 9 12.500000 937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 14.000000 777.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 16 29.500000 1637.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 187 380.000000 27650.0000 72.7632
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 429 808.386133 59541.1300 73.6543
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 77 148.000000 10610.0000 71.6892
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 122 239.500000 17313.5400 72.2904
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 98 189.000000 14005.0000 74.1005
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 116 214.000000 16040.0000 74.9533
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 145 294.500000 15948.5100 54.1545
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 402 732.500000 40045.1100 54.6691
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 157.000000 11775.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 121 192.500000 14437.5000 75.0000
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 2 2.000000 407.0000 203.5000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 4677.8200 275.1659
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 2.602742 132.8700 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 262.8000 43.8000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 24 25.000000 1225.2000 49.0080
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 8.5500 8.5500
OCTH-97167-OT EVAL HIGH COMPLEXITY 13 22.000000 1123.1000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 5.696376 290.8000 51.0500
SCREEN-T1023-SCREENING 18 18.000000 900.0000 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 54.000000 2695.8600 49.9233
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 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 10 13.000000 612.6000 47.1231
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 31.5200 31.5200
Subtotal (Total Children Is Unduplicated) 1255 3767.570051 251923.6100 66.8663
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 9.000000 4808.2600 534.2511
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 18 18.000000 900.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 931 4925.250000 245967.5000 49.9401
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 272 941.750000 47087.5000 50.0000
INTR-T1013-INTERPRETER 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 12.000000 120.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 374 1344.740617 92380.9400 68.6980
OCCT-97530GT-OT SESSION BY LICENSED OT 110 317.250000 22308.3500 70.3179
OCCT-97530HM-OT SESSION BY OT ASST 103 439.009614 24582.6900 55.9958
OCCT-97530HMGT-OT SESSION BY OT ASST 6 21.500000 1233.9700 57.3940
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 11.000000 785.8400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 360 1361.490342 92513.5300 67.9502
PHY-97110GT-PT SESSION BY LICENSED PT 76 260.250000 18287.6200 70.2694
PHY-97110HM-PT SESSION BY PT ASST 44 207.357767 11640.6700 56.1381
CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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-97110HMGT-PT SESSION BY LICENSED PT ASST 3 2.000000 114.3200 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 2 9.000000 642.9600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SENS-V5264-EARMOLD 2 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 913 3899.506861 269913.2800 69.2173
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 218 754.000000 53362.6600 70.7728
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 40.500000 2316.6000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 9 19.000000 1339.5000 70.5000
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.000000 27.5600 13.7800
Subtotal (Total Children Is Unduplicated) 2674 14606.60520 890916.3900 60.9941
-----------------------------------------------------------------------------------------------------------------------
Total 18417.175252 1144431.0000 62.1393
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3588
-----------------------------------------------------------------------------------------------------------------------
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 1662 1684.750000 90626.0700 90566.0700
D 105 105.500000 6141.4900 0.0000
S 1 1.000000 50.0000 0.0000
H 191 222.000000 13964.9900 0.0000
T 614 628.750000 34425.6700 33968.3750
44 47.500000 3215.8100 0.0000
Other 15 27.500000 1887.0000 0.0000
---------------------------------------------------------
Total 2632 2717.000000 150311.0300 124534.4450
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 616 538.000000 34536.1100 34536.1100
107 81.000000 4861.6300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 723 619.000000 39397.7400 34536.1100
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
585 721.500000 51054.6200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 585 721.500000 51054.6200 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 18 46.250000 2694.7500 2783.6900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 20.000000 1040.3500 0.0000
T 0 0.000000 0.0000 0.0000
96 114.000000 12103.5700 0.0000
Other 67 142.000000 9689.4400 595.0600
---------------------------------------------------------
Total 186 322.250000 25528.1100 3378.7500
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 106 176.000000 10098.9800 10098.9800
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
3 3.500000 86.7800 86.7800
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 109 179.500000 10185.7600 10185.7600
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 492 328.750000 20909.5900 20909.5900
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
868 822.250000 55299.7500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1360 1151.000000 76209.3400 20909.5900
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 228 443.750000 28732.4700 28732.4700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 27 54.000000 4050.0000 0.0000
T 0 0.000000 0.0000 0.0000
71 130.250000 8558.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 326 628.000000 41340.7200 28732.4700
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 182 404.000000 27186.1000 27541.6800
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 3 5.000000 189.5500 0.0000
204 493.000000 34146.6900 0.0000
Other 31 58.000000 4125.7500 0.0000
---------------------------------------------------------
Total 420 960.000000 65648.0900 27541.6800
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 1024 1754.250000 114503.1000 114181.6200
D 0 0.000000 0.0000 0.0000
S 10 14.000000 979.7700 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
851 1559.250000 105934.5400 240.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1885 3327.500000 221417.4100 114421.6200
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 190 476.750000 31446.8700 31446.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 3.000000 214.3200 214.3200
T 0 0.000000 0.0000 0.0000
48 108.750000 7487.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 239 588.500000 39149.0900 31661.1900
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 95 142.500000 7899.2100 6283.8500
D 131 150.250000 7849.5000 130.0000
S 2 3.000000 221.4400 112.5000
H 176 230.500000 15079.4000 328.9600
T 604 988.000000 59059.6900 55267.4700
368 643.750000 38306.7400 9.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1376 2158.000000 128415.9800 62131.7800
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 2 4.000000 261.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 20 20.000000 1292.0000 1292.0000
739 794.750000 50436.2400 0.0000
Other 26 25.750000 1839.5800 0.0000
---------------------------------------------------------
Total 787 844.500000 53828.8200 1292.0000
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 1 1.000000 71.4400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 167 171.830000 9800.0500 9800.0500
505 545.920000 35850.4100 0.0000
Other 49 48.000000 3418.4000 0.0000
---------------------------------------------------------
Total 722 766.750000 49140.3000 9800.0500
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 177 167.866784 11132.5700 11132.5700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 90 125.548000 8902.4600 0.0000
T 0 0.000000 0.0000 0.0000
600 596.760468 39271.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 867 890.175252 59306.5500 11132.5700
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 5.000000 263.6300 219.0000
D 6 6.500000 448.5000 0.0000
S 7 12.250000 675.0600 675.0600
H 0 0.000000 0.0000 0.0000
T 611 2036.000000 103340.6900 103340.6900
206 483.750000 28769.5600 18219.3100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 833 2543.500000 133497.4400 122454.0600