CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 12368 16179.00000 598484.2500 36.9914
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 646 603.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8783 26922.75000 996049.2500 36.9966
Subtotal (Total Children Is Unduplicated) 16874 43705.25000 1594533.5000 36.4838
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 39 43.000000 2085.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 9 9.000000 207.7000 23.0778
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 23.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 11 11.000000 160.3800 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 7 7.000000 68.5300 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 12 12.000000 344.6400 28.7200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 3 3.000000 134.2800 44.7600
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 3 3.000000 41.1300 13.7100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 7 7.000000 146.2300 20.8900
AUDE-92651-AEP HEARING STATUS DETER I&R 1 1.000000 83.1300 83.1300
AUDE-92652-AEP THRSHLD EST MLT FREQ I&R 1 1.000000 74.6000 74.6000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 130.0000 65.0000
EVAL-96111-DEVELOPMENTAL EVALUATION 35 66.250000 3312.5000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 5 12.000000 600.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 282 476.250000 23812.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 17.500000 1312.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 14 25.500000 1912.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.000000 675.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 12.000000 900.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 10 15.500000 1162.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 8 15.000000 1125.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 16.500000 1237.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 66 86.000000 4773.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 24 35.500000 1970.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 183 320.826832 24062.0125 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 335 599.743999 44794.3300 74.6891
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 48 84.336800 6325.2600 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 170 271.000000 20285.0000 74.8524
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 99 177.000000 13275.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 114 197.432133 14807.4100 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 323 597.500000 33161.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 739 1252.500000 69387.2500 55.3990
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 115 188.018600 14101.3950 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 189 301.500000 22575.0000 74.8756
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 33 33.000000 2372.0400 71.8800
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 7.000000 350.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 2 8.000000 400.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 14 14.000000 714.7000 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 10 10.000000 510.5000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 10 10.000000 510.5000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 267.0000 44.5000
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 11 12.000000 600.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 22 21.750000 1110.2900 51.0478
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 0.500000 25.5250 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 28 27.608227 1373.0800 49.7345
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 4.000000 204.2000 51.0500
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.5700 52.5700
Subtotal (Total Children Is Unduplicated) 1963 5052.216591 318783.3325 63.0977
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 26 66.000000 6080.2400 92.1248
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 3 3.000000 150.0000 50.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 927 986.250000 49235.0000 49.9214
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 1033 1101.000000 55050.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 386 360.750000 8968.7500 24.8614
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 906 1325.750000 66235.0000 49.9604
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 873 978.750000 48937.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 92 94.500000 2362.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 512 744.750000 37237.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 605 509.500000 25462.5000 49.9755
CONOP-CONOP-CONSULT, OT, PHONE 55 129.750000 3243.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 258 386.500000 19325.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 513 344.750000 17237.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 4.000000 100.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 658 888.750000 41987.5000 47.2433
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 845 749.500000 37475.0000 50.0000
CMS/EIP Fiscal Report Statewide
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 Page: 2
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
CONSP-CONSP-CONSULT, SLP, PHONE 91 80.250000 1981.2500 24.6885
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1143 2661.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 106 260.500000 13025.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2677 19107.25000 953951.6000 49.9262
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 727 3748.250000 187372.5000 49.9893
INTR-T1013-INTERPRETER 309 995.250000 51028.7500 51.2723
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 11679 95365.00000 954418.0000 10.0081
OCCT-97530-OT SESSION BY LICENSED OT 239 1220.470605 86658.8900 71.0045
OCCT-97530GT-OT SESSION BY LICENSED OT 28 105.500000 7288.6900 69.0871
OCCT-97530HM-OT SESSION BY OT ASST 44 249.187238 14239.2100 57.1426
OCCT-97530HMGT-OT SESSION BY OT ASST 3 6.167132 352.7600 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 246 1333.541711 93123.9100 69.8320
PHY-97110GT-PT SESSION BY LICENSED PT 30 113.250000 8090.5800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 18 114.303709 6533.6000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 3.500000 200.0600 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
SENS-V5264-EARMOLD 4 6.358888 114.4600 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 637 3824.056971 266508.2500 69.6925
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 83 222.397953 15638.1100 70.3159
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 8.000000 457.6000 57.2000
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 158 178.250000 6595.2500 37.0000
TRAV-TRAVS-Travel by mile 4452 404772.0000 177942.2300 0.4396
Subtotal (Total Children Is Unduplicated) 15213 543052.7342 3264894.2000 6.0121
-----------------------------------------------------------------------------------------------------------------------
Total 591810.200798 5178211.0325 8.7498
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 23483
-----------------------------------------------------------------------------------------------------------------------
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 17932 64493.500000 224920.8700 224911.7600
D 1220 7417.000000 10856.3700 0.0000
S 18 11.000000 407.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 21 202.250000 245.9900 236.7400
2539 1594.750000 62857.7300 0.0000
Other 21 6.750000 249.7500 0.0000
---------------------------------------------------------
Total 21751 73725.250000 299537.7100 225148.5000
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 2890 12127.500000 66073.1800 65872.1500
935 5407.500000 19990.5500 0.0000
Other 3977 6946.000000 72929.2000 0.0000
---------------------------------------------------------
Total 7802 24481.000000 158992.9300 65872.1500
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 1305 10577.500000 30946.8100 30946.8100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 73.000000 200.2500 200.2500
T 0 0.000000 0.0000 0.0000
9611 44904.750000 239289.5000 0.0000
Other 9 12.000000 839.4400 0.0000
---------------------------------------------------------
Total 10935 55567.250000 271276.0000 31147.0600
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 3232 11754.000000 192852.2300 192910.7300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 22.000000 700.0000 100.0000
T 0 0.000000 0.0000 0.0000
3101 3221.750000 135372.2900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6339 14997.750000 328924.5200 193010.7300
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 4968 57944.000000 157780.7700 157780.7700
D 1 0.500000 18.5000 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
3270 5047.000000 67690.8300 9267.8300
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 8239 62991.500000 225490.1000 167048.6000
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 9393 9340.250000 189771.5800 189771.5800
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
8634 6638.500000 193302.7200 0.0000
Other 214 139.000000 5143.0000 0.0000
---------------------------------------------------------
Total 18241 16117.750000 388217.3000 189771.5800
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 7842 21207.750000 402409.8400 402419.8400
D 13 16.750000 771.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 2 4.000000 300.0000 0.0000
T 0 0.000000 0.0000 0.0000
7099 3825.888100 140373.8575 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 14956 25054.388100 543855.4475 402419.8400
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 16237 146788.000000 826511.1700 826511.1700
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
397 7069.750000 32163.3900 0.0000
Other 24 38.500000 2457.6300 0.0000
---------------------------------------------------------
Total 16658 153896.250000 861132.1900 826511.1700
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 5957 19156.250000 493325.0250 493300.0250
D 13 12.500000 395.7200 0.0000
S 15 24.500000 1006.4400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5908 5074.750000 206756.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11893 24268.000000 701483.4350 493300.0250
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 1865 5482.250000 115916.0700 115916.0700
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
13 28.500000 1589.7900 30.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1878 5510.750000 117505.8600 115946.0700
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 2.250000 120.2500 0.0000
S 12 9.250000 342.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 4172 46368.000000 89255.9100 88134.5100
2141 1422.500000 41717.1200 122.8000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6327 47802.000000 131435.5300 88257.3100
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 10 7.000000 317.0000 0.0000
S 367 175.000000 6465.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 874 6287.000000 12690.9200 12690.9200
9347 14791.500000 159239.9100 0.0000
Other 34 31.250000 1156.2500 0.0000
---------------------------------------------------------
Total 10632 21291.750000 179869.8300 12690.9200
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 25 15.500000 649.5000 0.0000
S 226 180.250000 3203.2300 0.0000
H 0 0.000000 0.0000 0.0000
T 1512 9476.250000 30265.9000 30265.9000
10849 22004.250000 213680.5900 0.0000
Other 83 60.250000 2229.2500 0.0000
---------------------------------------------------------
Total 12695 31736.500000 250028.4700 30265.9000
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 5315 6799.907286 91180.4500 91180.4500
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
7617 6500.905412 179560.4700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12932 13300.812698 270740.9200 91180.4500
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 1 2.000000 150.0000 150.0000
S 19 36.000000 763.1500 763.1500
H 0 0.000000 0.0000 0.0000
T 4366 17157.250000 300583.8900 300583.8900
3609 3871.250000 148149.0000 1050.0000
Other 2 2.750000 74.7500 10.0000
---------------------------------------------------------
Total 7997 21069.250000 449720.7900 302557.0400