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: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 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 3 5.000000 250.0000 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 19 36.500000 2737.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 28 50.000000 3750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 16 30.500000 2287.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 411.0000 68.5000
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 4 8.500000 637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 45.500000 2525.2500 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 300 592.484265 43453.8200 73.3417
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 377 693.729866 51702.9300 74.5289
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 104 201.500000 14916.4900 74.0272
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 228 418.000000 31305.1500 74.8927
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 83 152.884534 11306.3400 73.9535
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 152 269.000000 20175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 223 415.000000 23032.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 536 987.000000 54628.5000 55.3480
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 179 298.500000 22387.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 115 222.549400 16628.7000 74.7191
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 28 28.000000 8512.0000 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) 1660 5049.911438 334609.3050 66.2604
-----------------------------------------------------------------------------------------------------------------------
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 315 1040.250000 51912.5000 49.9039
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:Program Patients
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) 2525 14213.23356 886774.9500 62.3908
-----------------------------------------------------------------------------------------------------------------------
Total 19304.894997 1222918.7550 63.3476
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 3853
-----------------------------------------------------------------------------------------------------------------------
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 297 321.500000 17157.9700 17157.9700
D 24 25.000000 1464.1400 0.0000
S 0 0.000000 0.0000 0.0000
H 258 308.750000 20973.7200 0.0000
T 561 576.750000 32233.1900 31794.5600
155 202.500000 13875.5000 0.0000
Other 33 57.500000 3932.2500 0.0000
---------------------------------------------------------
Total 1328 1492.000000 89636.7700 48952.5300
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 520 440.000000 35219.8800 35121.5700
84 63.250000 4149.1000 0.0000
Other 1 2.000000 111.0000 0.0000
---------------------------------------------------------
Total 605 505.250000 39479.9800 35121.5700
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
1015 1044.750000 55784.6800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1022 1051.750000 56178.6000 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
152 174.000000 19141.9800 0.0000
Other 106 246.500000 17474.2900 0.0000
---------------------------------------------------------
Total 285 479.000000 40196.4500 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 40 57.500000 2981.8900 2981.8900
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 0 0.000000 0.0000 0.0000
3 6.500000 447.1900 447.1900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 43 64.000000 3429.0800 3429.0800
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 328 243.750000 15313.9000 15313.9000
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
852 969.000000 65010.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1180 1212.750000 80324.0500 15313.9000
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 398 779.049400 52054.5900 52054.5900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 10.000000 750.0000 0.0000
T 0 0.000000 0.0000 0.0000
44 82.000000 6065.2000 0.0000
Other 5 10.000000 750.0000 0.0000
---------------------------------------------------------
Total 452 881.049400 59619.7900 52054.5900
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 435 1462.500000 89547.8500 89547.8500
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
364 867.000000 59672.5700 0.0000
Other 38 75.000000 5586.0000 0.0000
---------------------------------------------------------
Total 868 2899.500000 160069.9500 94811.3800
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
1150 1945.250000 128787.9650 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2574 4116.750000 275812.6550 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 65 93.000000 5112.2000 3659.5300
D 251 276.500000 15093.0000 165.0000
S 2 2.750000 203.9700 130.0000
H 240 299.000000 17836.3000 0.0000
T 670 908.500000 52759.4200 45343.1400
327 529.750000 31895.2400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1555 2109.500000 122900.1300 49297.6700
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
637 705.250000 45267.0000 0.0000
Other 2 2.000000 100.0000 0.0000
---------------------------------------------------------
Total 715 780.000000 50169.6100 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 78 82.000000 5495.8900 0.0000
T 155 164.500000 9214.2200 9214.2200
727 803.750000 51904.2000 0.0000
Other 1 0.500000 18.6000 0.0000
---------------------------------------------------------
Total 998 1085.750000 68908.1900 9214.2200
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 262 263.750000 17701.6000 17701.6000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 91 154.500000 11392.4700 0.0000
T 0 0.000000 0.0000 0.0000
728 722.834007 47089.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1081 1141.084007 76183.0800 17701.6000
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 25 28.413243 1949.8300 2329.5400
D 3 5.500000 373.5000 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
419 876.500000 58544.5000 28235.1600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 542 1157.011590 77982.6400 47679.5100