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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 69 158.500000 5861.2500 36.9795
Subtotal (Total Children Is Unduplicated) 69 158.500000 5861.2500 36.9795
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 36 37.000000 869.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 38 39.000000 568.6200 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 41 43.000000 420.9700 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 38 39.000000 1120.0800 28.7200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 40 42.000000 877.3800 20.8900
AUDE-92652-AEP THRSHLD EST MLT FREQ I&R 1 1.000000 74.6000 74.6000
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 21 39.000000 2812.5000 72.1154
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 29.000000 2175.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 14 27.500000 2062.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 13.000000 975.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 28.000000 1367.0000 48.8214
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 24 43.000000 2386.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 322 628.173167 45895.4875 73.0618
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 472 881.225734 65821.8600 74.6935
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 137 263.663200 19094.7400 72.4210
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 223 413.000000 30875.2100 74.7584
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 125 234.000000 17315.0000 73.9957
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 166 293.567867 22017.5900 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 215 422.000000 22914.0000 54.2986
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 547 1007.500000 55248.0000 54.8367
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 134 237.481400 17688.6150 74.4842
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 172 274.500000 20482.5000 74.6175
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 22 22.000000 5295.2800 240.6945
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 10.000000 510.5000 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 33 33.000000 1663.8400 50.4194
OCTH-97165GT-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 32 36.000000 1735.7000 48.2139
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 4.000000 164.2000 41.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 16 16.000000 795.0100 49.6881
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 4.000000 153.1500 38.2875
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 20 20.000000 990.5300 49.5265
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.000000 400.7100 50.0888
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 11 11.000000 511.5500 46.5045
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 25 26.000000 1250.0000 48.0769
SPCH-92521-EVAL OF SPEECH FLUENCY 34 41.500000 1975.1050 47.5929
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 0.500000 25.5200 51.0400
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 82 82.391773 4155.0500 50.4304
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 6 28.000000 1242.8200 44.3864
Subtotal (Total Children Is Unduplicated) 1761 5449.003141 358527.5175 65.7969
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 10.000000 3308.0600 330.8060
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 6 8.000000 400.0000 50.0000
AUDE-V5160-DISPENSING FEE BINAURAL 1 4.242869 975.8600 230.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 0.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 14 29.000000 1450.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 737 4505.500000 224493.1800 49.8265
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 175 511.000000 25540.0000 49.9804
OCCT-97530-OT SESSION BY LICENSED OT 469 2425.779555 166863.6086 68.7876
OCCT-97530GT-OT SESSION BY LICENSED OT 71 246.500000 16876.8840 68.4661
OCCT-97530HM-OT SESSION BY OT ASST 108 717.414656 39758.8386 55.4196
OCCT-97530HMGT-OT SESSION BY OT ASST 8 16.832867 962.8400 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 3 6.000000 428.6400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 512 2948.708288 202205.3700 68.5742
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110GT-PT SESSION BY LICENSED PT 61 206.000000 12981.8500 63.0187
PHY-97110HM-PT SESSION BY PT ASST 54 272.448389 15588.8300 57.2176
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 11 24.250000 1268.9700 52.3287
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SENS-V5264-EARMOLD 4 5.641112 87.8300 15.5696
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1076 6093.496884 425018.2466 69.7495
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 159 528.852041 36572.8900 69.1552
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 10 56.500000 3231.8000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 2634 18624.91666 1178517.3378 63.2764
-----------------------------------------------------------------------------------------------------------------------
Total 24232.419802 1542906.1053 63.6712
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3930
-----------------------------------------------------------------------------------------------------------------------
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 4245 4301.500000 240121.9000 240121.9000
D 78 81.500000 4744.0400 0.0000
S 3 1.500000 55.5000 0.0000
H 155 202.000000 13413.8000 0.0000
T 2 2.000000 121.4400 121.4400
280 274.750000 14684.5600 0.0000
Other 8 14.000000 1050.0000 0.0000
---------------------------------------------------------
Total 4771 4877.250000 274191.2400 240243.3400
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 0.500000 -35.7200 0.0000
H 0 0.000000 0.0000 0.0000
T 402 318.000000 19500.4600 19502.4600
265 189.500000 12356.9700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 668 508.000000 31821.7100 19502.4600
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 16 16.000000 1096.6000 1025.1600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.000000 142.8800 142.8800
T 0 0.000000 0.0000 0.0000
682 824.000000 57940.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 700 842.000000 59180.1600 1168.0400
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 112 241.250000 15176.4800 5784.1000
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
114 124.000000 12749.4700 0.0000
Other 88 200.000000 13798.9600 167.7000
---------------------------------------------------------
Total 314 565.250000 41724.9100 5951.8000
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 130 262.750000 13549.7100 13549.7100
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
22 50.500000 2342.7400 2342.7400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 152 313.250000 15892.4500 15892.4500
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 401 255.750000 15569.8500 15569.8500
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
1075 1025.250000 68284.9400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1476 1281.000000 83854.7900 15569.8500
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 582 1152.361900 76947.4025 76927.0000
D 8 16.000000 1200.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 14 28.000000 2100.0000 0.0000
T 0 0.000000 0.0000 0.0000
31 61.500000 4555.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 635 1257.861900 84802.9025 76927.0000
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 587 1637.750000 111732.8440 111796.4100
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 1 1.000000 51.0500 63.1400
248 485.750000 32405.1900 0.0000
Other 28 55.500000 4162.5000 0.0000
---------------------------------------------------------
Total 864 2180.000000 148351.5840 111859.5500
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 1964 2882.500000 188945.4500 188928.2900
D 6 5.500000 133.2000 0.0000
S 6 6.000000 168.9200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1058 1930.750000 131856.9850 0.0000
Other 2 4.000000 225.0000 0.0000
---------------------------------------------------------
Total 3036 4828.750000 321329.5550 188928.2900
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 224 664.000000 42987.3800 42987.3800
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
21 76.750000 5195.3600 428.6400
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 245 740.750000 48182.7400 43416.0200
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 94 132.250000 6857.8000 5534.1000
D 202 249.000000 13477.8800 260.0000
S 4 4.000000 200.0000 0.0000
H 158 207.500000 13283.7300 40.0000
T 661 1019.250000 60424.4600 54074.2100
516 964.750000 59112.2200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1635 2576.750000 153356.0900 59908.3100
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 0 0.000000 0.0000 0.0000
S 2 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 22 22.000000 1100.0000 1100.0000
739 793.750000 52089.8000 0.0000
Other 17 17.000000 1193.0400 0.0000
---------------------------------------------------------
Total 780 834.000000 54429.0900 1100.0000
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 1 1.000000 71.4400 0.0000
S 21 24.500000 1720.1000 0.0000
H 0 0.000000 0.0000 0.0000
T 152 154.080000 8707.3800 8707.3800
757 821.170000 52302.0900 0.0000
Other 23 23.000000 1600.2400 0.0000
---------------------------------------------------------
Total 954 1023.750000 64401.2500 8707.3800
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 253 249.936888 16304.0300 16304.0300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 49 63.000000 4430.0100 0.0000
T 0 0.000000 0.0000 0.0000
1114 1109.981041 75306.1386 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1416 1422.917929 96040.1786 16304.0300
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 17 14.696098 1025.1397 1073.1700
D 7 13.000000 819.0000 111.0000
S 1 1.000000 71.4400 71.4400
H 0 0.000000 0.0000 0.0000
T 69 133.119075 9050.3755 9050.3800
415 818.074800 54306.5000 17634.5600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 509 979.889973 65272.4552 27940.5500