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
Agency Filter:EXT
Payclass Filters:MED
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 66 76.000000 2812.0000 37.0000
Subtotal (Total Children Is Unduplicated) 66 76.000000 2812.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 70.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 43.7400 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 29.3700 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 86.1600 28.7200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 62.6700 20.8900
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 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 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 26 51.000000 2830.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 31.000000 2325.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 135 254.500000 19087.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.500000 712.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 100 193.426134 14506.9600 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 65 126.000000 9450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 98.500000 5466.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 243 446.500000 24780.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 32.500000 2437.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 67.500000 5062.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 24 24.000000 1225.2000 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 33 33.000000 1684.6500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
PSTF-97164TL-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 19 19.000000 969.9500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 12 12.000000 612.6000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 16.000000 816.8000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 21 21.000000 1072.0500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 740 1563.926134 100081.0000 63.9934
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.250000 56.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4095 32329.50000 1615876.0000 49.9815
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1157 5912.750000 295637.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 412 2188.500000 156346.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 38 177.000000 12644.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 190 1078.000000 61661.3100 57.1997
OCCT-97530HMGT-OT SESSION BY OT ASST 16 30.000000 1716.0000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 45 236.000000 16859.8400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 13 46.250000 3304.1000 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 3 21.000000 1201.2000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 46 355.750000 20348.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 409 2358.000000 168455.5200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 57 208.250000 14877.3800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 93 530.250000 30309.0900 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 4.500000 257.2200 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 33 170.000000 12144.8000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 4 15.250000 1089.4600 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 13 102.000000 5830.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 582 3354.000000 239437.0800 71.3885
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 62 266.750000 19056.6200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 31.500000 1801.8000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 146 874.250000 62456.4200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 12 45.000000 3214.8000 71.4400
SPL-92508HA-GROUP SPL SESSION PER CHILD 6 20.000000 277.6000 13.8800
Subtotal (Total Children Is Unduplicated) 6048 50356.75000 2744860.5300 54.5083
-----------------------------------------------------------------------------------------------------------------------
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
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Total 51996.676134 2847753.5300 54.7680
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 6479
-----------------------------------------------------------------------------------------------------------------------
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 0 0.000000 0.0000 0.0000
D 199 208.000000 11400.5000 0.0000
S 1 1.500000 83.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 79 133.500000 8715.7500 0.0000
---------------------------------------------------------
Total 279 343.000000 20199.5000 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 48 39.750000 1470.7500 0.0000
P 35 42.500000 2137.5900 899.1000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2371 8522.000000 430346.9300 0.0000
T 0 0.000000 0.0000 0.0000
12 9.500000 351.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2466 8613.750000 434306.7700 899.1000
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 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
6209 5981.000000 309782.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6209 5981.000000 309782.2000 0.0000
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 5 1.000000 37.0000 37.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5 1.000000 37.0000 37.0000
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 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
2232 7391.750000 411217.1600 0.0000
Other 88 168.500000 11331.0000 0.0000
---------------------------------------------------------
Total 2320 7560.250000 422548.1600 0.0000
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 1 4.000000 285.7600 0.0000
D 3 6.000000 428.6400 0.0000
S 15 24.500000 1168.9600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3949 12214.000000 699456.8800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3968 12248.500000 701340.2400 0.0000
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 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
620 1734.750000 103201.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 620 1734.750000 103201.7700 0.0000
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 1 1.000000 50.0000 50.0000
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
988 1929.500000 117013.5500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 989 1930.500000 117063.5500 50.0000
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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1174 1211.000000 62426.5200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1174 1211.000000 62426.5200 0.0000
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 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
1911 1989.750000 105477.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1911 1989.750000 105477.2500 0.0000
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 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
4309 4386.676134 268576.7200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4309 4386.676134 268576.7200 0.0000
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 1 1.000000 51.0500 51.0500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1672 5995.500000 302742.8000 302770.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1673 5996.500000 302793.8500 302821.8500