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: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 22 69.250000 2574.1000 37.1711
Subtotal (Total Children Is Unduplicated) 22 69.250000 2574.1000 37.1711
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 2.000000 396.8000 198.4000
AUD-92626-EVAL OF AUD REHAB STATUS 1 1.000000 56.1000 56.1000
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 13.8000 13.8000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 28 29.000000 565.7900 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 30 31.000000 455.0800 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 32 33.000000 237.6000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 28 29.000000 838.6800 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 45.0800 45.0800
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 27 28.000000 589.1200 21.0400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 45.3200 45.3200
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
EVAL-96111-DEVELOPMENTAL EVALUATION 4 6.000000 300.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 4 7.000000 350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 25.000000 1875.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 21.000000 1575.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 9 17.000000 1275.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 13.500000 1012.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 10.500000 768.0000 73.1429
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 21.000000 1165.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 19 38.000000 2059.8600 54.2068
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 228 453.272401 32957.9300 72.7111
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 344 638.666667 47765.0000 74.7886
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 88 173.666667 12650.0000 72.8407
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 205 371.000000 27730.0000 74.7439
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 71 139.000000 10255.0000 73.7770
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 151 273.500000 20470.5000 74.8464
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 179 343.500000 19064.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 465 855.500000 47433.2500 55.4451
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 97 180.900000 13567.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 131 217.500000 16312.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 5548.1500 292.0079
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 50.0000 50.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 386.0000 193.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 6.505738 334.4600 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 13 13.000000 668.3300 51.4100
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 14 16.000000 719.7400 44.9838
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 25 25.000000 1285.2500 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 12 12.000000 568.4800 47.3733
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 9 8.500000 360.3550 42.3947
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SCREEN-T1023-SCREENING 7 8.000000 354.0000 44.2500
SPCH-92521-EVAL OF SPEECH FLUENCY 46 46.000000 2364.8525 51.4098
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 35 37.000000 1799.3500 48.6311
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 16 56.000000 2870.2700 51.2548
Subtotal (Total Children Is Unduplicated) 1352 4252.511473 281824.0375 66.2724
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 13 26.000000 11944.6000 459.4077
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.500000 75.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 7 5.500000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 12 10.750000 537.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 649 2403.250000 119962.5000 49.9168
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 96 214.250000 10712.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 421 1876.864237 132363.7600 70.5239
OCCT-97530GT-OT SESSION BY LICENSED OT 45 75.250000 5235.3300 69.5725
OCCT-97530HM-OT SESSION BY OT ASST 90 590.079860 32048.1700 54.3116
OCCT-97530HMGT-OT SESSION BY OT ASST 2 6.500000 374.4000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 3 2.500000 179.9000 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 410 1782.355054 122602.4800 68.7868
PHY-97110GT-PT SESSION BY LICENSED PT 43 90.500000 6006.5900 66.3712
PHY-97110HM-PT SESSION BY PT ASST 38 171.290131 9776.3100 57.0746
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 11 22.250000 1222.5500 54.9461
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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 459.2200 459.2200
SENS-V5264-EARMOLD 2 4.000000 72.5200 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 856 4260.116748 295889.9200 69.4558
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 107 332.500000 23277.6000 70.0078
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 13.500000 777.6000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 2.000000 115.2000 57.6000
Subtotal (Total Children Is Unduplicated) 2195 11897.95603 773755.6100 65.0327
-----------------------------------------------------------------------------------------------------------------------
Total 16219.717503 1058153.7475 65.2387
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3302
-----------------------------------------------------------------------------------------------------------------------
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 698 707.000000 41670.1900 41670.1900
D 36 39.000000 2297.6400 0.0000
S 0 0.000000 0.0000 0.0000
H 165 198.000000 13446.7700 0.0000
T 919 927.500000 49956.6500 49823.0700
77 91.750000 6191.8800 0.0000
Other 13 21.500000 1524.7500 0.0000
---------------------------------------------------------
Total 1908 1984.750000 115087.8800 91493.2600
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 401 326.750000 28295.2000 28295.2000
115 92.750000 7703.5000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 516 419.500000 35998.7000 28295.2000
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 46 50.000000 3085.1100 3085.1100
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
75 72.750000 4029.6900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 121 122.750000 7114.8000 3085.1100
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 82 150.000000 10050.7100 6415.6000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 1.000000 27.8600 27.8600
T 0 0.000000 0.0000 0.0000
106 116.500000 12725.6500 0.0000
Other 38 78.000000 5489.5800 0.0000
---------------------------------------------------------
Total 227 345.500000 28293.8000 6443.4600
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 43 66.500000 3240.1500 3240.1500
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
2 2.000000 96.7500 96.7500
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 45 68.500000 3336.9000 3336.9000
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 223 152.250000 9233.9600 9233.9600
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
956 1026.250000 66736.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1179 1178.500000 75970.1100 9233.9600
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 318 662.900000 45721.8000 45721.8000
D 4 8.000000 600.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 11 22.000000 1650.0000 0.0000
T 0 0.000000 0.0000 0.0000
42 84.000000 6300.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 375 776.900000 54271.8000 45721.8000
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 379 1088.250000 76294.5100 76685.5500
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 163 481.500000 30317.5900 30317.5900
205 432.000000 29010.1600 0.0000
Other 44 84.500000 6259.5000 0.0000
---------------------------------------------------------
Total 791 2086.250000 141881.7600 107003.1400
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 1009 1633.250000 109387.8200 108698.3200
D 2 1.250000 89.9500 0.0000
S 18 18.000000 404.6200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
986 1720.250000 113579.9175 0.0000
Other 6 12.500000 810.7500 0.0000
---------------------------------------------------------
Total 2021 3385.250000 224273.0575 108698.3200
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 131 366.750000 24485.8600 24485.8600
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
1 2.000000 143.9200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 132 368.750000 24629.7800 24485.8600
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 65 104.000000 6208.1900 4306.6800
D 211 231.000000 12387.4600 0.0000
S 0 0.000000 0.0000 0.0000
H 136 178.750000 11769.2800 0.0000
T 472 656.750000 38702.3900 33661.6300
495 748.250000 45056.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1379 1918.750000 114123.4200 37968.3100
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 8 4.000000 148.4500 0.0000
S 9 12.000000 821.9600 0.0000
H 10 10.000000 675.6800 0.0000
T 12 12.000000 621.9600 621.9600
564 614.500000 40571.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 603 652.500000 42839.1200 621.9600
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 1 0.500000 35.9800 35.9800
D 64 68.000000 3641.1700 0.0000
S 0 0.000000 0.0000 0.0000
H 23 22.500000 1619.1000 0.0000
T 112 119.010000 6569.7000 6569.7000
709 781.990000 50044.6900 0.0000
Other 1 0.250000 9.2500 0.0000
---------------------------------------------------------
Total 910 992.250000 61919.8900 6605.6800
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 251 256.000000 16622.8500 16622.8500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 48 72.500000 5126.5900 0.0000
T 0 0.000000 0.0000 0.0000
671 625.072885 41277.2000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 970 953.572885 63026.6400 16622.8500
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 35 46.537128 3312.9800 3584.8600
D 0 0.000000 0.0000 0.0000
S 5 11.500000 719.8000 719.8000
H 5 5.000000 97.9500 97.9500
T 103 262.957490 18698.5700 18698.5700
316 639.000000 42505.3800 16982.1300
Other 1 1.000000 51.4100 51.4100
---------------------------------------------------------
Total 465 965.994618 65386.0900 40134.7200