CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 20.250000 749.2500 37.0000
Subtotal (Total Children Is Unduplicated) 8 20.250000 749.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 10 10.000000 235.0000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 15 15.000000 218.7000 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 18 18.000000 176.2200 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 18 18.000000 516.9600 28.7200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 63.1400 63.1400
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 11 11.000000 229.7900 20.8900
EVAL-96111-DEVELOPMENTAL EVALUATION 3 6.000000 300.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 4.000000 200.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 4 7.000000 350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.500000 487.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 22 42.000000 3150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 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 8 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 22 40.000000 2170.0000 54.2500
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 199 404.500000 30105.6500 74.4268
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 326 634.672840 46946.2130 73.9692
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 68 137.500000 9972.5000 72.5273
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 144 269.145200 20116.6400 74.7427
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 65 125.000000 9375.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 98 179.628266 13080.3200 72.8188
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 123 248.000000 13764.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 365 693.500000 37905.4500 54.6582
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 159.500000 11962.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 142 258.769100 19407.6825 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 4256.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 16 15.500000 722.3350 46.6023
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 25 25.500000 1250.7200 49.0478
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 82.1000 41.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 21 20.555338 1049.3500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 6.000000 300.7500 50.1250
PSTH-97161-PT EVAL LOW COMPLEXITY 11 9.750000 497.7250 51.0487
PSTH-97162-PT EVAL MODERATE COMPLEXITY 14 13.500000 689.1700 51.0496
PSTH-97163-PT EVAL HIGH COMPLEXITY 8 8.599804 439.0200 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 8 9.000000 400.0000 44.4444
SPCH-92521-EVAL OF SPEECH FLUENCY 24 22.750000 1161.3750 51.0495
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 58 60.000000 3063.0000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 541.5500 49.2318
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 7 7.000000 357.3500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 1197 3571.370548 239457.8105 67.0493
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 5 7.000000 1303.1500 186.1643
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 4 5.000000 250.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 0.250000 12.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 2.500000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 639 3147.000000 157010.0000 49.8920
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 208 626.750000 31337.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 4.000000 40.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 374 1374.175533 95029.1700 69.1536
OCCT-97530GT-OT SESSION BY LICENSED OT 90 225.500000 15946.2500 70.7151
OCCT-97530HM-OT SESSION BY OT ASST 109 525.133916 29614.0600 56.3933
OCCT-97530HMGT-OT SESSION BY OT ASST 9 23.000000 1315.6000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 9.750000 696.5400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 446 1819.863384 128033.1800 70.3532
PHY-97110GT-PT SESSION BY LICENSED PT 73 192.500000 13528.1300 70.2760
PHY-97110HM-PT SESSION BY PT ASST 37 189.575372 10756.6484 56.7407
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 7 12.750000 728.7900 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
SENS-V5264-EARMOLD 3 3.000000 54.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 933 4099.094764 289754.9000 70.6875
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 201 644.785414 45215.4700 70.1248
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 26.500000 1515.8000 57.2000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 2 9.000000 514.8000 57.2000
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 1.000000 71.4400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 1 77.000000 34.2600 0.4449
Subtotal (Total Children Is Unduplicated) 2341 13033.12838 823269.3884 63.1674
-----------------------------------------------------------------------------------------------------------------------
Total 16624.748931 1063476.4489 63.9695
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3190
-----------------------------------------------------------------------------------------------------------------------
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 1561 1567.750000 86102.3300 86052.3300
D 197 214.500000 12492.4800 0.0000
S 1 1.000000 71.4400 0.0000
H 119 131.750000 8539.2600 0.0000
T 876 888.750000 48583.8400 48068.0700
29 39.000000 2681.9000 0.0000
Other 3 6.000000 450.0000 0.0000
---------------------------------------------------------
Total 2786 2848.750000 158921.2500 134120.4000
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 1.000000 71.4400 71.4400
H 0 0.000000 0.0000 0.0000
T 785 642.750000 38374.0900 38374.0900
214 144.750000 7255.4900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1000 788.500000 45701.0200 38445.5300
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
498 625.500000 45063.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 498 625.500000 45063.8500 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 35 65.000000 4416.8700 1640.8300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 11 28.000000 1843.2000 0.0000
T 0 0.000000 0.0000 0.0000
59 64.500000 7955.7500 0.0000
Other 61 121.000000 8283.4600 0.0000
---------------------------------------------------------
Total 166 278.500000 22499.2800 1640.8300
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 112 167.250000 10087.1400 10087.1400
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
17 35.000000 1801.2500 1801.2500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 129 202.250000 11888.3900 11888.3900
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 520 318.000000 20352.3000 20352.3000
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
768 719.750000 52320.7100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1288 1037.750000 72673.0100 20352.3000
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 317 542.691940 35743.9155 35743.9100
D 3 6.000000 450.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 7 14.000000 1050.0000 0.0000
T 0 0.000000 0.0000 0.0000
29 58.000000 4350.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 356 620.691940 41593.9155 35743.9100
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 240 574.500000 38176.4400 38439.9200
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 6.000000 333.0000 0.0000
295 693.750000 47576.4400 225.0000
Other 53 104.000000 7800.0000 0.0000
---------------------------------------------------------
Total 591 1378.250000 93885.8800 38664.9200
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 1118 1676.750000 113284.0500 113284.0500
D 1 2.000000 142.8800 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
819 1603.250000 109309.2950 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1938 3282.000000 222736.2250 113284.0500
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 141 384.500000 25685.5700 25685.5700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 71.4400 71.4400
T 0 0.000000 0.0000 0.0000
31 98.000000 6436.1200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 173 483.500000 32193.1300 25757.0100
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 50 70.500000 3497.0600 2410.8100
D 169 185.250000 9488.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 88 111.500000 6922.5000 0.0000
T 468 786.000000 42083.9500 37854.3500
453 784.500000 49413.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1228 1937.750000 111405.6100 40265.1600
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 17 17.000000 850.0000 850.0000
652 695.750000 45568.8900 0.0000
Other 8 8.000000 571.5200 0.0000
---------------------------------------------------------
Total 677 720.750000 46990.4100 850.0000
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 5 8.000000 592.8800 0.0000
H 0 0.000000 0.0000 0.0000
T 155 163.000000 9427.1200 9427.1200
663 711.000000 46254.6900 0.0000
Other 10 10.000000 714.4000 0.0000
---------------------------------------------------------
Total 833 892.000000 56989.0900 9427.1200
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 225 230.250000 15093.4400 15093.4400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 72 114.000000 8143.2000 0.0000
T 0 0.000000 0.0000 0.0000
798 760.306991 50248.1984 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1095 1104.556991 73484.8384 15093.4400
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 2 3.000000 195.7500 400.0000
D 0 0.000000 0.0000 0.0000
S 2 2.000000 102.1000 102.1000
H 0 0.000000 0.0000 0.0000
T 21 46.000000 2848.8800 2848.8800
191 372.000000 24252.7700 6182.7700
Other 1 1.000000 51.0500 51.0500
---------------------------------------------------------
Total 217 424.000000 27450.5500 9584.8000