CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:GR
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 10376 14036.25000 519176.2500 36.9882
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 313 254.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 6897 21244.00000 785796.7500 36.9891
Subtotal (Total Children Is Unduplicated) 14083 35534.75000 1304973.0000 36.7239
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 14 14.000000 679.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 62.2400 20.7467
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 4 4.000000 57.6100 14.4025
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 4 4.000000 38.4500 9.6125
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.000000 141.8200 28.3640
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 62.6700 20.8900
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.0000 45.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 230.0000 115.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 22 26.250000 1312.5000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 6 12.000000 600.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 300 498.500000 24925.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 15.000000 1125.0000 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 8 11.000000 825.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 12.500000 937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 24.500000 1359.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 24 41.500000 2303.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 63 118.298600 8800.2950 74.3905
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 243 433.996500 32498.3875 74.8817
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 69.000000 4899.8800 71.0128
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 129 212.500000 15937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 54.500000 4087.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 98 184.000000 13800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 204 371.500000 20618.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 457 780.000000 43290.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 140.000000 10500.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 134 217.000000 16205.5000 74.6797
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 1 1.000000 30.3500 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 32 32.000000 2077.0500 64.9078
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 46.8400 23.4200
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 5.000000 250.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 1.804113 92.1000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 31 30.142801 1503.8400 49.8905
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 254.2000 50.8400
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 30 31.000000 1502.3000 48.4613
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 8 9.000000 459.4500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1407 3421.492014 214426.3325 62.6704
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 18 35.000000 7263.7900 207.5369
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 682 793.500000 39550.0000 49.8425
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 868 931.250000 46543.7500 49.9799
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 271 269.250000 6731.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 747 967.000000 48312.5000 49.9612
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 997 1323.000000 66150.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 108 115.750000 2881.2500 24.8920
CONOF-CONOF-CONSULT, OT, FACE TO FACE 437 559.000000 27950.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 645 569.500000 28475.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 59 90.500000 2262.5000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 179 231.250000 11562.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 523 343.500000 17175.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 22 13.250000 331.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 544 642.250000 32112.5000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 947 896.500000 44825.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 82 91.250000 2268.7500 24.8630
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 2
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 735 1526.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 14.250000 356.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2260 13810.25000 686734.6700 49.7264
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 701 3276.750000 163737.5000 49.9695
INTR-T1013-INTERPRETER 231 925.750000 47756.2500 51.5866
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10109 81124.00000 810805.0000 9.9946
OCCT-97530-OT SESSION BY LICENSED OT 225 1107.038910 77266.6000 69.7957
OCCT-97530GT-OT SESSION BY LICENSED OT 32 85.300112 6079.6000 71.2731
OCCT-97530HM-OT SESSION BY OT ASST 43 196.334963 11224.2100 57.1687
OCCT-97530HMGT-OT SESSION BY OT ASST 1 4.000000 228.8000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 179 943.360018 64808.0600 68.6992
PHY-97110GT-PT SESSION BY LICENSED PT 31 118.250000 8379.5600 70.8631
PHY-97110HM-PT SESSION BY PT ASST 25 127.460464 7072.1300 55.4849
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 8.250000 457.3100 55.4315
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 4 7.750000 553.6600 71.4400
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 2 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 511 3004.423161 205220.7000 68.3062
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 75 295.000000 21074.8000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 166 185.250000 6854.2500 37.0000
TRAV-TRAVS-Travel by mile 2996 251755.0000 111006.2200 0.4409
Subtotal (Total Children Is Unduplicated) 13552 366400.1676 2615372.1300 7.1380
-----------------------------------------------------------------------------------------------------------------------
Total 405356.409642 4134771.4625 10.2003
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 20469
-----------------------------------------------------------------------------------------------------------------------
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 11173 40142.000000 151048.9500 151048.9500
D 1369 6704.250000 17530.1600 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 1333 5145.250000 16633.1700 16633.1700
392 287.250000 14356.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14268 52279.000000 199578.4500 167682.1200
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 12 12.000000 160.0000 160.0000
H 0 0.000000 0.0000 0.0000
T 3107 12302.500000 65241.4000 65241.4000
135 2308.250000 2082.9100 0.0000
Other 2504 1376.750000 47283.3800 0.0000
---------------------------------------------------------
Total 5758 15999.500000 114767.6900 65401.4000
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 1664 14583.500000 42010.4600 42010.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 52 441.250000 1695.3500 1695.3500
T 0 0.000000 0.0000 0.0000
5969 20942.000000 140545.1500 0.0000
Other 4 5.000000 367.8800 0.0000
---------------------------------------------------------
Total 7689 35971.750000 184618.8400 43705.8100
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 3138 11234.500000 186908.8700 186898.8700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 43.000000 430.0000 430.0000
T 0 0.000000 0.0000 0.0000
2644 2882.750000 119708.2400 0.0000
Other 11 31.000000 941.7200 941.7200
---------------------------------------------------------
Total 5805 14191.250000 307988.8300 188270.5900
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 4375 25541.500000 139901.7900 139901.7900
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
2127 1980.750000 42366.5100 2277.0100
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6502 27522.250000 182268.3000 142178.8000
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 7696 7644.750000 147249.5200 147249.5200
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
7988 6038.000000 166517.9100 0.0000
Other 192 141.250000 5226.2500 0.0000
---------------------------------------------------------
Total 15876 13824.000000 318993.6800 147249.5200
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 5655 14629.000000 284230.2300 284240.2300
D 18 16.250000 677.2500 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
6654 3642.545100 133437.3825 290.0000
Other 8 5.500000 194.2500 0.0000
---------------------------------------------------------
Total 12335 18293.295100 418539.1125 284530.2300
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 14137 96221.750000 694119.6000 694119.6000
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 261 6308.750000 21817.8500 21817.8500
0 0.000000 0.0000 0.0000
Other 10 18.000000 1411.0000 0.0000
---------------------------------------------------------
Total 14408 102548.500000 717348.4500 715937.4500
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 5437 17874.750000 409174.9000 409174.9000
D 2 3.000000 214.3200 0.0000
S 41 66.000000 1393.2400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4717 4291.000000 172218.0000 0.0000
Other 2 4.000000 261.0000 0.0000
---------------------------------------------------------
Total 10199 22238.750000 583261.4600 409174.9000
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 1635 8146.000000 110265.4900 110265.4900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 10.000000 407.2000 407.2000
T 0 0.000000 0.0000 0.0000
51 100.000000 5679.2900 308.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1688 8256.000000 116351.9800 110980.6900
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 0 0.000000 0.0000 0.0000
D 2 3.000000 161.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4160 46517.250000 87954.6200 86310.2200
2223 1422.000000 42581.9900 14.2400
Other 3 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 6388 47943.250000 130734.6100 86324.4600
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 15 18.000000 779.0000 0.0000
S 18 13.750000 618.9400 92.5000
H 0 0.000000 0.0000 0.0000
T 70 70.500000 3395.3100 3395.3100
6591 5585.250000 123883.5200 0.0000
Other 24 18.250000 675.2500 0.0000
---------------------------------------------------------
Total 6718 5705.750000 129352.0200 3487.8100
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 1 1.750000 64.7500 64.7500
D 18 17.750000 1225.1800 0.0000
S 14 9.500000 325.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 454 2037.250000 16864.9500 16864.9500
6728 6782.750000 169447.6800 0.0000
Other 77 47.000000 1739.0000 0.0000
---------------------------------------------------------
Total 7292 8896.000000 189666.8100 16929.7000
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 6905 10039.515218 116739.0600 116739.0600
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
4940 4166.099324 100930.9300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11845 14205.614542 217669.9900 116739.0600
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 15 18.000000 752.6000 752.6000
H 0 0.000000 0.0000 0.0000
T 3536 13902.500000 188129.1400 188101.1400
2335 3558.000000 134639.5000 0.0000
Other 3 3.000000 110.0000 110.0000
---------------------------------------------------------
Total 5889 17481.500000 323631.2400 188963.7400