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:MED
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 13095 38771.75000 1441268.4000 37.1732
Subtotal (Total Children Is Unduplicated) 13095 38771.75000 1441268.4000 37.1732
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 28 54.000000 4050.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 35 64.500000 4798.5000 74.3953
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 39 68.500000 5108.2500 74.5730
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 14 26.500000 1987.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 10 19.000000 1425.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 20.000000 1500.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 12 23.000000 1725.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 47.000000 2608.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 72 129.500000 7084.5000 54.7066
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 406 765.000000 57375.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 761 1342.333333 100645.7500 74.9782
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 137 246.500000 18487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 459 767.000000 57486.0000 74.9492
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 149 281.500000 21075.0000 74.8668
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 286 520.000000 39000.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 501 939.000000 52114.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1257 2180.000000 120990.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 261 477.500000 35812.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 296 520.000000 39000.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 1294.5500 76.1500
OCTF-97168-OT RE-EVAL EST PLAN CARE 14 15.000000 771.1500 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 14 14.000000 719.7400 51.4100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 565.5100 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 17 17.000000 873.9700 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 29 29.000000 1450.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 23 23.500000 1206.6950 51.3487
SPCH-92522TL-EVAL OF SPCH SOUND PROD 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 18 18.000000 925.3800 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 411.2800 51.4100
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.4100 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.7200 44.8600
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 5 14.000000 741.0200 52.9300
Subtotal (Total Children Is Unduplicated) 2661 8696.333333 583153.3450 67.0574
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4417 28346.25000 1416882.5000 49.9848
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1155 4964.250000 248212.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 455 1975.035159 141996.6700 71.8958
OCCT-97530GT-OT SESSION BY LICENSED OT 41 93.000000 6656.3000 71.5731
OCCT-97530HM-OT SESSION BY OT ASST 157 829.250000 47764.2600 57.5993
OCCT-97530HMGT-OT SESSION BY OT ASST 5 10.500000 590.3800 56.2267
OCCT-97530TL-OT SESSION BY LICENSED OT 101 377.750000 27182.8900 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 38 81.000000 5828.7600 71.9600
OCCT-97530TLGTHM-OT SESSION BY OT ASST 1 0.500000 28.8000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 12 82.000000 4723.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 387 1679.000000 120511.4300 71.7757
PHY-97110GT-PT SESSION BY LICENSED PT 14 54.500000 3921.8200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 73 431.000000 24802.2100 57.5457
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 12.000000 690.7200 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 132 498.250000 35854.0700 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 21 26.500000 1906.9400 71.9600
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.5600 57.5600
PHY-97110TLHM-PT SESSION BY PT ASST 6 35.000000 2014.6000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 585 3320.250000 238901.4300 71.9528
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 68 220.500000 15831.2000 71.7968
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 33.500000 1929.6000 57.6000
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:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 150 668.500000 48042.7800 71.8665
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 46 110.750000 7969.5700 71.9600
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 27.9200 13.9600
Subtotal (Total Children Is Unduplicated) 6427 43852.28516 2402328.1100 54.7823
-----------------------------------------------------------------------------------------------------------------------
Total 91320.368492 4426749.8550 48.4749
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 14633
-----------------------------------------------------------------------------------------------------------------------
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 59 60.000000 3100.7500 0.0000
S 3583 2420.750000 104391.5200 0.0000
H 0 0.000000 0.0000 0.0000
T 2 2.000000 1.0400 1.0400
0 0.000000 0.0000 0.0000
Other 129 177.750000 11976.7500 0.0000
---------------------------------------------------------
Total 3773 2660.500000 119470.0600 1.0400
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 1179 926.250000 41078.2000 0.0000
---------------------------------------------------------
Total 1179 926.250000 41078.2000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 46 27.500000 1023.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2134 1542.500000 59636.0000 0.0000
P 43 51.750000 2316.5500 2316.5500
D 3 4.250000 214.8000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 150.0000
T 0 0.000000 0.0000 0.0000
10 12.000000 686.0000 0.0000
Other 165 174.500000 6784.7000 0.0000
---------------------------------------------------------
Total 2402 1814.500000 70811.0500 2466.5500
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 86 118.000000 4671.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 1782 2648.000000 106442.1000 0.0000
P 890 1451.500000 58265.2500 53938.1500
D 56 70.750000 2851.5000 0.0000
S 1 0.750000 27.9000 0.0000
H 1560 5769.500000 290950.5800 100.0000
T 0 0.000000 0.0000 0.0000
510 625.000000 30301.6500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4885 10683.500000 493510.8800 54038.1500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 3.000000 111.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 2937 1814.750000 67462.1000 31536.1400
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
2 0.750000 27.9000 0.0000
Other 35 24.250000 901.0000 0.0000
---------------------------------------------------------
Total 2980 1842.750000 68502.6000 31536.1400
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
10789 9578.250000 451538.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10789 9578.250000 451538.3100 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.250000 455.7000 0.0000
U 0 0.000000 0.0000 0.0000
B 1028 825.750000 36201.7000 0.0000
P 1597 1419.250000 64136.7000 71390.0000
D 0 0.000000 0.0000 0.0000
S 16 14.500000 539.4000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
26 17.750000 811.5000 0.0000
Other 139 76.500000 2845.7500 0.0000
---------------------------------------------------------
Total 2821 2366.000000 104990.7500 71390.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 6.000000 259.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 1792 2024.750000 82251.6700 5241.5600
P 2103 2308.750000 93369.8200 93151.4800
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 6 3.000000 111.6000 111.0000
1941 6416.750000 352782.6200 0.0000
Other 154 291.000000 20044.9500 0.0000
---------------------------------------------------------
Total 6004 11050.250000 548820.4600 98504.0400
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 49 42.250000 1796.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 8558 7520.250000 321693.0500 0.0000
P 4 13.250000 935.5200 137.5000
D 115 146.000000 8613.5600 0.0000
S 387 248.750000 9760.1200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3797 10872.000000 622552.9650 0.0000
Other 630 591.250000 24890.1000 0.0000
---------------------------------------------------------
Total 13540 19433.750000 990241.4150 137.5000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 10 14.500000 999.7500 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
380 1132.000000 69691.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 390 1146.500000 70691.5200 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 37 40.750000 2754.7200 0.0000
U 0 0.000000 0.0000 0.0000
B 1068 1071.000000 51655.2400 27.9000
P 820 847.750000 40293.4000 161156.9800
D 0 0.000000 0.0000 0.0000
S 117 89.250000 3357.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 143.9200 0.0000
645 1059.500000 62825.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2688 3110.250000 161029.9400 161184.8800
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 46 45.250000 2766.2800 0.0000
U 0 0.000000 0.0000 0.0000
B 838 787.000000 41522.6200 18.6000
P 1912 1757.250000 87316.8500 87284.2800
D 104 91.750000 4429.3600 0.0000
S 31 33.000000 1887.3800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1220 1225.750000 62348.8400 0.0000
Other 126 100.000000 4021.9900 0.0000
---------------------------------------------------------
Total 4277 4040.000000 204293.3200 87302.8800
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 39 43.000000 2752.9200 0.0000
U 0 0.000000 0.0000 0.0000
B 1148 1093.750000 51758.8600 46.5000
P 4109 3650.500000 167956.6300 167739.1200
D 74 77.500000 4419.6800 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
1750 1879.500000 98457.8100 0.0000
Other 115 90.750000 4057.7600 1285.9500
---------------------------------------------------------
Total 7235 6835.000000 329403.6600 169071.5700
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2053 1819.250000 80171.9100 0.0000
P 903 860.500000 35522.1500 35522.0000
D 0 0.000000 0.0000 0.0000
S 1 1.333333 100.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3217 3311.500000 197424.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6174 5992.583333 313218.8500 35522.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 148 213.750000 7951.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2057 3058.500000 131236.5000 0.0000
P 909 1413.250000 63856.0900 63846.4960
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 88 138.250000 5199.6000 5082.9600
1286 4731.535159 240303.8000 239876.0000
Other 259 285.000000 10601.3500 0.0000
---------------------------------------------------------
Total 4747 9840.285159 459148.8400 308805.4560