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: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 14 22.000000 814.0000 37.0000
Subtotal (Total Children Is Unduplicated) 15 22.500000 832.5000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 15 16.000000 314.3900 19.6494
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 18 19.000000 276.3100 14.5426
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 17 17.000000 165.0100 9.7065
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 17.000000 487.4700 28.6747
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 14 15.000000 293.9700 19.5980
EXIT-EXIT-EXIT ASSESSMENT 8 10.000000 500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 21.000000 1536.0000 73.1429
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 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 550.0000 68.7500
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 23.000000 1094.0000 47.5652
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 190 382.701400 27495.1050 71.8448
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 358 663.503500 48984.9925 73.8278
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 67 138.000000 9885.0000 71.6304
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 137 255.573866 18801.2300 73.5648
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 64 120.000000 8830.0000 73.5833
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 86 153.000000 11475.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 135 268.000000 14742.0000 55.0075
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 347 630.500000 34166.2500 54.1891
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 85 166.500000 12487.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 150 301.000000 22575.0000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 304.0000 304.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 11 11.000000 2866.7900 260.6173
OCTF-97168-OT RE-EVAL EST PLAN CARE 8 7.195886 367.3500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 11 11.000000 561.5500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 23 24.000000 1174.1500 48.9229
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 28 28.357199 1447.6300 51.0498
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 4.000000 204.2000 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 326.6900 54.4483
PSTH-97162-PT EVAL MODERATE COMPLEXITY 16 16.000000 759.5700 47.4731
PSTH-97163-PT EVAL HIGH COMPLEXITY 13 16.897159 862.6000 51.0500
SCREEN-T1023-SCREENING 13 14.000000 650.0000 46.4286
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 71 73.000000 3747.0400 51.3293
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 8.000000 408.4000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 34 36.250000 1697.4000 46.8248
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 4 4.000000 178.2000 44.5500
Subtotal (Total Children Is Unduplicated) 1226 3541.979010 233989.5975 66.0618
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 10 15.000000 1666.8300 111.1220
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 943 5627.500000 281150.0000 49.9600
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 243 918.750000 45937.5000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 150.0000 75.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 7 16.000000 160.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 405 1950.461082 133414.8500 68.4017
OCCT-97530GT-OT SESSION BY LICENSED OT 92 282.199888 19416.5700 68.8043
OCCT-97530HM-OT SESSION BY OT ASST 123 704.165035 38991.5400 55.3727
OCCT-97530HMGT-OT SESSION BY OT ASST 7 31.250000 1787.5000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 4 5.000000 357.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 427 2227.610027 151937.3700 68.2064
PHY-97110GT-PT SESSION BY LICENSED PT 74 219.250035 15355.2200 70.0352
PHY-97110HM-PT SESSION BY PT ASST 39 263.215181 14988.6000 56.9443
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 5 8.064556 460.9700 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1028 5479.076848 375855.3900 68.5983
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 184 679.750000 48289.4600 71.0400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 39.500000 2259.4000 57.2000
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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 0.750000 53.5800 71.4400
TRAV-TRAVS-Travel by mile 3 42.000000 18.6800 0.4448
Subtotal (Total Children Is Unduplicated) 2757 18523.29265 1132816.8000 61.1563
-----------------------------------------------------------------------------------------------------------------------
Total 22087.771662 1367638.8975 61.9184
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3556
-----------------------------------------------------------------------------------------------------------------------
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 2651 2671.000000 146015.1100 146015.1100
D 244 257.500000 14898.3100 50.0000
S 1 2.000000 150.0000 0.0000
H 158 191.750000 12272.3100 0.0000
T 247 246.000000 13031.0600 12897.3300
25 26.750000 1910.9400 0.0000
Other 12 21.000000 1458.0000 0.0000
---------------------------------------------------------
Total 3338 3416.000000 189735.7300 158962.4400
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 4 3.500000 185.7200 185.7200
H 0 0.000000 0.0000 0.0000
T 1227 1010.250000 56616.8400 56489.8400
13 15.250000 1028.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1244 1029.000000 57831.5000 56675.5600
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 36 35.750000 2177.6300 2177.6300
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
511 623.500000 44919.7700 0.0000
Other 8 14.000000 1050.0000 0.0000
---------------------------------------------------------
Total 555 673.250000 48147.4000 2177.6300
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 72 154.000000 10337.6900 3722.1000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 29.000000 1671.7600 0.0000
T 0 0.000000 0.0000 0.0000
77 143.500000 13033.2900 0.0000
Other 88 214.000000 14624.6200 1078.7600
---------------------------------------------------------
Total 245 540.500000 39667.3600 4800.8600
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 119 233.750000 12131.2400 12131.2400
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
12 36.000000 2312.6500 2312.6500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 131 269.750000 14443.8900 14443.8900
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 501 305.250000 19555.6500 19555.6500
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
1052 923.000000 61573.3400 0.0000
Other 1 0.750000 27.7500 0.0000
---------------------------------------------------------
Total 1554 1229.000000 81156.7400 19555.6500
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 405 878.954900 56999.7575 56856.8700
D 3 6.000000 450.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 10.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
46 90.750000 6777.7500 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 460 986.204900 64996.0075 56856.8700
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 316 822.500000 54776.0400 55141.3500
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 30 66.500000 3995.8000 3962.5500
165 380.250000 26499.0900 0.0000
Other 5 10.000000 711.0000 0.0000
---------------------------------------------------------
Total 516 1279.250000 85981.9300 59103.9000
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 1396 2201.250000 146713.0000 146522.9600
D 1 1.000000 71.4400 0.0000
S 8 11.000000 521.5300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1004 1826.250000 124480.3300 0.0000
Other 2 2.500000 158.2500 0.0000
---------------------------------------------------------
Total 2411 4042.000000 271944.5500 146522.9600
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 226 635.750000 41943.1900 41943.1900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 12.000000 821.5600 821.5600
T 0 0.000000 0.0000 0.0000
53 140.500000 8922.1900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 283 788.250000 51686.9400 42764.7500
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 126 156.500000 8422.0100 6167.9900
D 200 215.500000 10965.0000 130.0000
S 1 2.000000 150.0000 130.0000
H 161 205.000000 13001.3200 35.0000
T 718 1184.000000 71660.6800 67084.9900
378 694.500000 41109.5700 0.0000
Other 1 0.500000 18.5000 0.0000
---------------------------------------------------------
Total 1585 2458.000000 145327.0800 73547.9800
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 0 0.000000 0.0000 0.0000
S 12 14.000000 953.6400 0.0000
H 0 0.000000 0.0000 0.0000
T 33 34.000000 1735.2500 1735.2500
652 668.250000 42487.7800 0.0000
Other 70 70.000000 5017.4800 0.0000
---------------------------------------------------------
Total 767 786.250000 50194.1500 1735.2500
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 0 0.000000 0.0000 0.0000
S 2 2.000000 121.4400 0.0000
H 0 0.000000 0.0000 0.0000
T 122 131.640000 7030.2700 7030.2700
582 624.860000 40277.8600 0.0000
Other 41 42.000000 2814.6400 0.0000
---------------------------------------------------------
Total 747 800.500000 50244.2100 7030.2700
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 394 394.032475 25742.3500 25742.3500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 92 126.000000 9016.9800 0.0000
T 0 0.000000 0.0000 0.0000
993 971.534236 60430.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1479 1491.566711 95189.8800 25742.3500
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 11 8.140472 565.1800 843.2200
D 0 0.000000 0.0000 0.0000
S 4 4.000000 204.2000 204.2000
H 0 0.000000 0.0000 0.0000
T 607 1995.609579 101528.4300 98896.0100
148 290.500000 18793.7200 6864.2200
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 770 2298.250051 121091.5300 106807.6500