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: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 11945 15182.50000 564539.8000 37.1836
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 791 798.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 9040 27296.00000 1015150.8000 37.1905
Subtotal (Total Children Is Unduplicated) 16647 43277.25000 1579690.6000 36.5016
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 17 19.000000 921.5000 48.5000
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 2 2.000000 27.6000 13.8000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 9 9.000000 175.5900 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 19 19.000000 272.6300 14.3489
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 16 16.000000 115.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 17 17.000000 491.6400 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 4 4.000000 55.2400 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 9 9.000000 189.3600 21.0400
AUDE-92652-AEP THRSHLD EST MLT FREQ I&R 1 1.000000 75.1300 75.1300
AUDE-V5010-ASSESSMENT FOR HEARING AID 1 1.000000 28.9900 28.9900
EVAL-96111-DEVELOPMENTAL EVALUATION 42 63.000000 3150.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 5 9.500000 475.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 258 369.250000 18406.2500 49.8477
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 17 30.000000 2250.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 20 34.000000 2550.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 18 33.500000 2512.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 12.000000 900.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 10.500000 787.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 20.000000 1361.6700 68.0835
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 13.000000 975.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 32.000000 1776.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 35 60.000000 3330.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 182 315.242131 23378.1600 74.1594
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 219 379.770133 28443.7600 74.8973
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 70 120.000000 8912.5000 74.2708
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 131 235.500000 17662.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 63 113.615466 8486.7000 74.6967
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 106 183.000000 13725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 418 765.000000 42429.7500 55.4637
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 415 741.000000 41125.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 148 243.000000 18225.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 87 165.950600 12446.2950 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 1 1.000000 76.1500 76.1500
NURS-T1001-NURSING ASSESSMENT 2 3.000000 150.0000 50.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 5 24.000000 1200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 21 120.000000 6000.0000 50.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 7 7.000000 359.8700 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 17 17.000000 873.9700 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 9 8.858588 455.4200 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 26 27.000000 1336.6900 49.5070
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 4.805485 232.9400 48.4738
PSTF-97164GT-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 5 5.000000 257.0500 51.4100
SCREEN-T1023-SCREENING 18 18.000000 900.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 40 43.832912 2238.8700 51.0774
SPCH-92521GT-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 32 31.309473 1568.3000 50.0903
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 31.9700 31.9700
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 8 25.000000 1260.5100 50.4204
Subtotal (Total Children Is Unduplicated) 1717 4403.134788 273763.7650 62.1747
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 32 68.000000 13867.4900 203.9337
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 231.6200 231.6200
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 710 771.500000 38337.5000 49.6922
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 727 759.750000 37837.5000 49.8026
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 315 315.750000 7681.2500 24.3270
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 686 917.250000 44931.2500 48.9847
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 821 783.250000 38310.0000 48.9116
CONIP-CONIP-CONSULT, ITDS PHONE 71 69.250000 1718.7500 24.8195
CONOF-CONOF-CONSULT, OT, FACE TO FACE 495 588.750000 29437.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 600 465.000000 23212.5000 49.9194
CONOP-CONOP-CONSULT, OT, PHONE 53 96.750000 2418.7500 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 238 330.250000 16468.7500 49.8675
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 532 373.750000 18687.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 7 5.000000 125.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 536 630.500000 30975.0000 49.1277
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 704 607.750000 30387.5000 50.0000
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:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
CONSP-CONSP-CONSULT, SLP, PHONE 45 46.000000 1150.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1172 3177.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 18.000000 450.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 96 364.500000 18062.5000 49.5542
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2464 14727.50000 734570.0000 49.8774
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 516 2196.000000 109800.0000 50.0000
INTR-T1013-INTERPRETER 280 1032.750000 46976.0100 45.4863
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 11112 72451.00000 721285.0000 9.9555
OCCT-97530-OT SESSION BY LICENSED OT 235 1174.223319 82053.8800 69.8793
OCCT-97530GT-OT SESSION BY LICENSED OT 31 94.250000 6236.2300 66.1669
OCCT-97530HM-OT SESSION BY OT ASST 59 283.340279 16053.7600 56.6589
OCCT-97530HMGT-OT SESSION BY OT ASST 1 3.000000 172.8000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 2 3.000000 215.8800 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 214 910.251390 64652.8700 71.0275
PHY-97110GT-PT SESSION BY LICENSED PT 18 35.250000 2412.8400 68.4494
PHY-97110HM-PT SESSION BY PT ASST 26 132.421995 7622.2100 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 4.000000 230.2400 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 4 9.000000 647.6400 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.500000 35.9800 71.9600
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 2 2.000000 604.0600 302.0300
SENS-V5264-EARMOLD 3 5.000000 66.4200 13.2840
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 559 2731.279463 191975.0800 70.2876
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 76 250.750000 17850.6600 71.1891
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 6 16.000000 1151.3600 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 6.000000 431.7600 71.9600
SPL-92508HA-GROUP SPL SESSION PER CHILD 1 1.000000 13.9600 13.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 84 87.000000 3219.0000 37.0000
TRAV-TRAVS-Travel by mile 3965 302743.0000 134117.0700 0.4430
Subtotal (Total Children Is Unduplicated) 13762 409289.5164 2496828.9900 6.1004
-----------------------------------------------------------------------------------------------------------------------
Total 456969.901234 4350283.3550 9.5198
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 22756
-----------------------------------------------------------------------------------------------------------------------
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 2185 8634.750000 36508.1400 36508.1400
D 156 862.000000 1943.7800 0.0000
S 17 7.750000 288.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 2926 9811.500000 41440.2200 41530.2200
2047 1406.000000 60106.2700 60.0000
Other 3 0.750000 27.9000 0.0000
---------------------------------------------------------
Total 7334 20722.750000 140314.6100 78098.3600
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 1.000000 10.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3007 13128.500000 66828.1700 66958.4260
763 1626.250000 14442.7600 0.0000
Other 3410 12138.750000 61627.7100 0.0000
---------------------------------------------------------
Total 7181 26894.500000 142908.6400 66958.4260
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 56 392.500000 1888.2100 1888.2100
D 0 0.000000 0.0000 0.0000
S 11 124.000000 507.8100 507.8100
H 29 250.000000 483.2200 483.2200
T 0 0.000000 0.0000 0.0000
8611 52740.500000 178743.7200 0.0000
Other 2 2.000000 87.2000 0.0000
---------------------------------------------------------
Total 8709 53509.000000 181710.1600 2879.2400
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 2076 7546.500000 131133.8200 131133.8200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 37 143.500000 5985.9800 260.0000
T 0 0.000000 0.0000 0.0000
3232 3738.000000 149750.0000 0.0000
Other 13 27.500000 1444.4600 240.0000
---------------------------------------------------------
Total 5358 11455.500000 288314.2600 131633.8200
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 5725 60269.250000 182642.5900 182642.5900
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
3757 3332.250000 74125.8800 7119.6800
Other 6 1.750000 65.1000 0.0000
---------------------------------------------------------
Total 9488 63603.250000 256833.5700 189762.2700
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 7675 7608.000000 158618.7000 158618.7000
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
7396 5471.500000 168450.6100 0.0000
Other 269 176.000000 7438.4200 0.0000
---------------------------------------------------------
Total 15340 13255.500000 334507.7300 158618.7000
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 4553 11763.750000 244836.9300 244836.9300
D 2 1.500000 55.8000 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
6460 3398.950600 124375.7950 0.0000
Other 14 8.000000 297.6000 0.0000
---------------------------------------------------------
Total 11029 15172.200600 369566.1250 244836.9300
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 9288 70323.000000 411385.0700 411385.0700
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 285 10215.250000 25444.6900 25444.6900
4492 15363.250000 176453.1000 0.0000
Other 32 63.000000 4385.0000 0.0000
---------------------------------------------------------
Total 14097 95964.500000 617667.8600 436829.7600
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 5854 18814.500000 470048.8600 470048.9400
D 13 15.750000 365.3200 0.0000
S 40 55.000000 1036.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5695 4675.500000 184239.5000 40.0000
Other 7 4.000000 148.8000 0.0000
---------------------------------------------------------
Total 11609 23564.750000 655839.2300 470088.9400
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 1253 3954.250000 96848.6300 96848.6300
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
7 15.500000 969.9700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1260 3969.750000 97818.6000 96848.6300
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 1 0.250000 9.3000 9.3000
D 17 19.500000 1008.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3182 31597.250000 65042.3900 63789.3500
2342 1422.500000 44481.4100 0.0000
Other 1 2.000000 100.0000 100.0000
---------------------------------------------------------
Total 5543 33041.500000 110641.1000 63898.6500
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 201 137.000000 6204.1400 0.0000
S 77 60.000000 1533.8000 0.0000
H 0 0.000000 0.0000 0.0000
T 1313 11565.500000 17344.1500 17344.1500
10184 15059.000000 170716.4300 0.0000
Other 20 19.250000 885.0000 0.0000
---------------------------------------------------------
Total 11795 26840.750000 196683.5200 17344.1500
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 149 105.500000 4938.7200 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2424 18062.250000 38464.2200 38464.2200
11199 19729.500000 201402.0800 0.0000
Other 56 39.500000 1545.0000 0.0000
---------------------------------------------------------
Total 13828 37936.750000 246350.0200 38464.2200
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 5176 6283.705680 112812.5100 112812.5100
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
7395 5972.756537 185294.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 12571 12256.462217 298107.3200 112812.5100
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 2 8.000000 80.0000 80.0000
D 0 0.000000 0.0000 0.0000
S 13 17.000000 503.0100 503.0100
H 13 13.000000 904.8700 904.8700
T 3761 15062.738417 268662.0200 268553.7800
3499 3675.750000 142732.8000 450.0000
Other 5 6.250000 137.9100 91.4100
---------------------------------------------------------
Total 7293 18782.738417 413020.6100 270583.0700