CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 11213 13588.00000 505134.5500 37.1750
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 603 540.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 8324 24296.75000 903141.7500 37.1713
Subtotal (Total Children Is Unduplicated) 15604 38425.50000 1408276.3000 36.6495
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 20 22.000000 1067.0000 48.5000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 58.5300 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.000000 73.4000 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 5 5.000000 36.0000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 6 6.000000 173.5200 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 27.6200 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
AUDE-V5010-ASSESSMENT FOR HEARING AID 2 2.000000 90.6400 45.3200
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 2.000000 231.6200 115.8100
EVAL-96111-DEVELOPMENTAL EVALUATION 46 72.750000 3637.5000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 7 16.000000 800.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 273 393.000000 19650.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 19 34.500000 2587.5000 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 10 18.000000 1350.0000 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 11 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 5.000000 365.2500 73.0500
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 27.500000 1526.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 30 54.500000 3024.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 110 204.727599 15304.5700 74.7558
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 266 469.500000 35212.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 64 118.333333 8775.0000 74.1549
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 157 259.500000 19462.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 44 81.500000 6112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 103 179.000000 13387.5000 74.7905
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 336 614.000000 34021.5000 55.4096
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 594 959.500000 53252.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 160.100000 12007.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 93 161.000000 11934.9300 74.1300
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 46 46.000000 3502.9000 76.1500
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.2300 142.2300
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 9.000000 450.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 16 67.000000 3350.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 2.494261 128.2300 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 13 13.000000 643.3300 49.4869
OCTH-97166-OT EVAL MODERATE COMPLEXITY 6 6.000000 229.9400 38.3233
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 21 21.000000 1079.6100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 7 7.000000 359.8700 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 9.000000 462.6900 51.4100
SCREEN-T1023-SCREENING 23 23.000000 1150.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 15 16.250000 834.6900 51.3655
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 20 19.250000 957.1400 49.7216
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 462.6900 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 3 5.000000 200.4300 40.0860
Subtotal (Total Children Is Unduplicated) 1736 4183.405193 261928.7200 62.6114
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 18 39.000000 5824.6800 149.3508
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 649 738.250000 36631.2500 49.6190
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 801 841.500000 41950.0000 49.8515
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 251 245.250000 6006.2500 24.4903
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 591 730.000000 36387.5000 49.8459
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 709 696.750000 34825.0000 49.9821
CONIP-CONIP-CONSULT, ITDS PHONE 70 77.000000 1868.7500 24.2695
CONOF-CONOF-CONSULT, OT, FACE TO FACE 382 460.000000 22950.0000 49.8913
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 591 438.750000 21925.0000 49.9715
CONOP-CONOP-CONSULT, OT, PHONE 42 77.000000 1875.0000 24.3506
CONPF-CONPF-CONSULT, PT, FACE TO FACE 207 271.500000 13537.5000 49.8619
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 494 341.500000 17075.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 4.750000 118.7500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 463 508.500000 25425.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 668 574.250000 28712.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 47 45.250000 1131.2500 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 991 2767.750000 0.0000 0.0000
CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 104 318.000000 15900.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2514 14717.50000 734775.0000 49.9253
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 514 2074.500000 103725.0000 50.0000
INTR-T1013-INTERPRETER 276 972.500000 49150.7500 50.5406
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 10869 68544.00000 685915.0000 10.0069
OCCT-97530-OT SESSION BY LICENSED OT 225 1053.879935 74447.4800 70.6413
OCCT-97530GT-OT SESSION BY LICENSED OT 20 78.500000 5318.5400 67.7521
OCCT-97530HM-OT SESSION BY OT ASST 55 251.685243 14434.4000 57.3510
OCCT-97530HMGT-OT SESSION BY OT ASST 3 8.000000 460.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 218 959.394934 67903.3100 70.7772
PHY-97110GT-PT SESSION BY LICENSED PT 15 37.000000 2512.5200 67.9059
PHY-97110HM-PT SESSION BY PT ASST 23 115.959869 6674.6500 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 4.000000 230.2400 57.5600
SENS-V5050-IN EAR MONAURAL HEARING AID 1 2.000000 456.0000 228.0000
SENS-V5264-EARMOLD 3 5.000000 90.3900 18.0780
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 563 2800.383695 196705.6500 70.2424
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 64 157.250000 11187.0700 71.1419
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 145 131.500000 4865.5000 37.0000
TRAV-TRAVS-Travel by mile 4006 287588.0000 126055.0200 0.4383
Subtotal (Total Children Is Unduplicated) 13720 388676.0537 2397050.7500 6.1672
-----------------------------------------------------------------------------------------------------------------------
Total 431284.958869 4067255.7700 9.4306
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 22067
-----------------------------------------------------------------------------------------------------------------------
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 4579 23319.000000 60473.7900 60473.7900
D 514 3095.500000 6442.2900 0.0000
S 4 1.750000 65.1000 0.0000
H 0 0.000000 0.0000 0.0000
T 4270 11742.250000 56320.7400 56300.7400
1705 1074.750000 41989.4500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11072 39233.250000 165291.3700 116774.5300
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 2434 11494.750000 52838.3200 52810.9000
348 1343.750000 5471.9800 0.0000
Other 2643 6634.750000 51011.5200 0.0000
---------------------------------------------------------
Total 5425 19473.250000 109321.8200 52810.9000
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 2463 18399.000000 56715.3300 56715.3300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 73 469.000000 1534.3200 1534.3200
T 0 0.000000 0.0000 0.0000
3760 10099.250000 92947.5400 0.0000
Other 2 2.500000 133.2500 0.0000
---------------------------------------------------------
Total 6298 28969.750000 151330.4400 58249.6500
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 2222 8081.250000 137919.8900 138009.8900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 31 113.000000 4170.0000 370.0000
T 0 0.000000 0.0000 0.0000
2833 2774.250000 115934.0700 0.0000
Other 3 3.500000 231.3100 107.9400
---------------------------------------------------------
Total 5089 10972.000000 258255.2700 138487.8300
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 4502 47831.750000 144433.4700 144433.4700
D 1 0.250000 9.2500 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
3466 2315.750000 68552.6800 3045.1300
Other 5 3.000000 111.6000 0.0000
---------------------------------------------------------
Total 7974 50150.750000 213107.0000 147478.6000
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 7920 7885.500000 164742.7700 164742.7700
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
8064 6095.250000 182757.6700 0.0000
Other 270 190.000000 7242.2300 0.0000
---------------------------------------------------------
Total 16254 14170.750000 354742.6700 164742.7700
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 4259 11623.250000 226427.2500 226417.2500
D 7 4.250000 158.1000 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
5625 3066.350000 111608.6000 120.0000
Other 1 2.000000 74.4000 0.0000
---------------------------------------------------------
Total 9892 14695.850000 338268.3500 226537.2500
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 9496 76536.250000 462824.1900 462814.8900
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 4503 42939.000000 199434.5700 199434.5700
4 7.000000 768.9400 0.0000
Other 15 29.000000 2106.7500 0.0000
---------------------------------------------------------
Total 14018 119511.250000 665134.4500 662249.4600
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 5351 17038.500000 436550.5600 436550.5600
D 13 14.500000 441.8600 0.0000
S 35 44.250000 1530.2800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5079 4446.250000 178700.8500 100.0000
Other 4 2.750000 102.3000 0.0000
---------------------------------------------------------
Total 10482 21546.250000 617325.8500 436650.5600
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 1231 3600.250000 83888.1500 83888.1500
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
8 15.000000 732.1300 40.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1239 3615.250000 84620.2800 83928.1500
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 30 34.250000 1849.3000 0.0000
S 10 3.500000 129.8500 0.0000
H 0 0.000000 0.0000 0.0000
T 3037 28221.000000 55911.6400 55210.7000
2146 1402.750000 41229.1200 80.0000
Other 1 1.000000 37.2000 0.0000
---------------------------------------------------------
Total 5224 29662.500000 99157.1100 55290.7000
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 162 93.250000 3433.3000 0.0000
S 97 85.500000 2070.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1342 10776.750000 18555.7200 18555.7200
8664 11328.500000 146460.5400 0.0000
Other 17 14.000000 520.6000 0.0000
---------------------------------------------------------
Total 10282 22298.000000 171040.1600 18555.7200
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 130 89.250000 3977.7400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2161 13516.500000 33694.8400 33244.8400
10295 16869.250000 185046.0400 0.0000
Other 39 28.500000 1134.8000 0.0000
---------------------------------------------------------
Total 12625 30503.500000 223853.4200 33244.8400
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 5456 6517.953489 115481.9600 115481.9600
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
5932 4106.155380 136125.1700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 11388 10624.108869 251607.1300 115481.9600
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 12 36.000000 480.0000 480.0000
H 5 5.000000 122.0000 122.0000
T 3110 12096.750000 216896.4600 216896.4600
3550 3705.250000 146493.3900 287.8400
Other 7 15.000000 190.0000 190.0000
---------------------------------------------------------
Total 6684 15858.000000 364181.8500 217976.3000