CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 2 1.000000 37.2000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 26 40.250000 1497.3000 37.2000
Subtotal (Total Children Is Unduplicated) 28 41.750000 1534.5000 36.7545
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 13.8000 13.8000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 33 33.000000 643.8300 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 38 38.000000 557.8400 14.6800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 43 43.000000 309.6000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 40 40.000000 1156.8000 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 55.2400 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 34 34.000000 715.3600 21.0400
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 28.0000 28.0000
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.8100 115.8100
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 27.000000 2025.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 25 45.500000 3412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 13 26.000000 1950.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 261.0000 65.2500
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 3.500000 262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 38.000000 2109.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 24 46.000000 2553.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 211 424.958666 31191.9000 73.3998
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 254 479.229866 35640.6800 74.3707
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 80 157.000000 11678.9900 74.3885
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 171 322.000000 24105.1500 74.8607
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 70 125.384534 9403.8400 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 92 169.000000 12675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 159 304.500000 16899.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 371 703.000000 38866.5000 55.2866
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 139 240.000000 18000.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 71 138.049400 10291.2000 74.5472
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 24 24.000000 7296.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 11 11.000000 565.5100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 21 21.000000 1033.8900 49.2329
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 18 18.141412 932.6500 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 719.7400 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 4.194515 215.6400 51.4100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 15 16.000000 732.5900 45.7869
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
SCREEN-T1023-SCREENING 14 14.000000 700.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 66 65.167089 3247.0050 49.8258
SPCH-92521GT-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 39 40.760357 2095.4900 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 308.4600 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 26 88.000000 4064.7200 46.1900
Subtotal (Total Children Is Unduplicated) 1260 3814.885839 249593.1350 65.4261
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 11 20.000000 9787.1900 489.3595
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 3 6.000000 125.0000 20.8333
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 2.000000 18.7500 9.3750
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 4.000000 50.0000 12.5000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 4 4.250000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 31 72.000000 3050.0000 42.3611
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 579 2058.250000 101885.0000 49.5008
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 314 1038.250000 51812.5000 49.9037
INTR-T1013-INTERPRETER 1 2.000000 100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 471 2090.026684 147657.7900 70.6488
OCCT-97530GT-OT SESSION BY LICENSED OT 50 132.000000 9315.1200 70.5691
OCCT-97530HM-OT SESSION BY OT ASST 93 621.409722 35878.3400 57.7370
OCCT-97530HMGT-OT SESSION BY OT ASST 5 11.750000 675.9000 57.5234
OCCT-97530TL-OT SESSION BY LICENSED OT 2 5.000000 359.8000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 511 2171.248608 153172.0400 70.5456
PHY-97110GT-PT SESSION BY LICENSED PT 41 102.500000 6925.7800 67.5686
CMS/EIP Fiscal Report Statewide
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 Page: 2
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110HM-PT SESSION BY PT ASST 37 208.078005 11886.4300 57.1249
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 11 19.000000 1104.4400 58.1284
PHY-97110TL-PT SESSION BY LICENSED PT 2 7.000000 503.7200 71.9600
SENS-V5264-EARMOLD 2 2.000000 36.2600 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 967 4702.470540 330894.0800 70.3660
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 96 295.500000 20224.9200 68.4430
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 172.8000 57.6000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 3 7.000000 503.7200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.500000 179.9000 71.9600
TRAV-TRAVS-Travel by mile 16 618.000000 255.4700 0.4134
Subtotal (Total Children Is Unduplicated) 2524 14211.23356 886674.9500 62.3925
-----------------------------------------------------------------------------------------------------------------------
Total 18067.869398 1137802.5850 62.9738
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3452
-----------------------------------------------------------------------------------------------------------------------
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 296 320.000000 17045.4700 17045.4700
D 24 25.000000 1464.1400 0.0000
S 0 0.000000 0.0000 0.0000
H 240 281.750000 19065.7200 0.0000
T 555 568.750000 31730.6900 31292.0600
133 171.000000 11591.0000 0.0000
Other 22 41.000000 2841.0000 0.0000
---------------------------------------------------------
Total 1270 1407.500000 83738.0200 48337.5300
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 509 421.000000 33794.8800 33696.5700
84 63.250000 4149.1000 0.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 594 486.250000 38054.9800 33696.5700
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 3 3.000000 193.9200 193.9200
D 0 0.000000 0.0000 0.0000
S 4 4.000000 200.0000 200.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1004 1027.250000 54658.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1011 1034.250000 55052.6000 393.9200
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 27 58.500000 3580.1800 3580.1800
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
124 142.500000 15931.7300 0.0000
Other 106 246.500000 17474.2900 0.0000
---------------------------------------------------------
Total 257 447.500000 36986.2000 3580.1800
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 39 56.000000 2869.3900 2869.3900
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
3 6.500000 447.1900 447.1900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 42 62.500000 3316.5800 3316.5800
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 326 240.750000 15088.9000 15088.9000
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
774 851.000000 56910.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1100 1091.750000 71999.8000 15088.9000
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 393 769.049400 51304.5900 51304.5900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 8.000000 600.0000 0.0000
T 0 0.000000 0.0000 0.0000
36 66.000000 4865.2000 0.0000
Other 5 10.000000 750.0000 0.0000
---------------------------------------------------------
Total 438 853.049400 57519.7900 51304.5900
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 420 1434.000000 87468.8500 87468.8500
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 31 495.000000 5263.5300 5263.5300
323 790.500000 54851.5700 0.0000
Other 22 43.000000 3186.0000 0.0000
---------------------------------------------------------
Total 796 2762.500000 150769.9500 92732.3800
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 1383 2129.000000 145692.7700 145692.7700
D 4 3.500000 251.8600 0.0000
S 37 39.000000 1080.0600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1018 1713.250000 113202.9650 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2442 3884.750000 260227.6550 145692.7700
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 94 291.250000 19387.7800 19387.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 8.000000 575.6800 575.6800
T 0 0.000000 0.0000 0.0000
9 30.250000 2064.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 104 329.500000 22027.7800 19963.4600
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 56 75.000000 3998.2000 2832.9000
D 238 250.500000 13494.0000 165.0000
S 2 2.750000 203.9700 130.0000
H 222 264.000000 15552.5500 0.0000
T 647 863.000000 49922.9200 42706.6400
316 507.750000 30423.2400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1481 1963.000000 113594.8800 45834.5400
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 1 1.000000 71.9600 72.0000
D 27 23.250000 1572.9000 0.0000
S 1 1.500000 150.0000 0.0000
H 42 42.000000 2821.6300 0.0000
T 5 5.000000 186.1200 186.1200
605 648.750000 41478.0000 0.0000
Other 2 2.000000 100.0000 0.0000
---------------------------------------------------------
Total 683 723.500000 46380.6100 258.1200
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 37 35.000000 2275.2800 0.0000
S 0 0.000000 0.0000 0.0000
H 77 80.000000 5345.8900 0.0000
T 152 159.500000 8936.7200 8936.7200
678 716.250000 45819.4500 0.0000
Other 1 0.500000 18.6000 0.0000
---------------------------------------------------------
Total 945 991.250000 62395.9400 8936.7200
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 259 257.750000 17251.6000 17251.6000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 70 112.500000 8292.4700 0.0000
T 0 0.000000 0.0000 0.0000
709 688.308408 44549.5900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1038 1058.558408 70093.6600 17251.6000
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 23 25.413243 1754.0800 1988.4200
D 2 4.000000 261.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 95 246.598347 17114.8100 17114.8100
309 696.000000 46514.2500 28235.1600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 429 972.011590 65644.1400 47338.3900